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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610100
Report Date: 02/18/2025
Date Signed: 02/18/2025 01:11:16 PM

Document Has Been Signed on 02/18/2025 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HAPPY PLACE ELDER CAREFACILITY NUMBER:
197610100
ADMINISTRATOR/
DIRECTOR:		JAVIER, HERMAN B.FACILITY TYPE:
740
ADDRESS:23609 DAISETTA DRIVETELEPHONE:
(661) 505-7600
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 6CENSUS: 6DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Herman JavierTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced annual inspection. LPA arrived at the facility and was allowed to enter Marie Orillo. She was informed the reason of the visit. LPA observed another staff on duty. The Administrator Herman Javier was contacted and arrived later during the visit.

A physical plant inspection was conducted with caregivers. LPA observed the front entrance, as a screening area, with sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. Signs to wear a mask was posted on the facility front door. The following was observed during the physical plant inspection: The facility has seven (7) bedrooms and three (3) bathrooms. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory and a hospice waiver for four (4).

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and clean in good repair. The following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with dining The smoke detectors are hardwired and inter connected and observed to be operational. The facility is equipped with sprinkler system. The fire extinguisher was located in the kitchen and observed to be filled and current.
The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.
Food Service/Kitchen: LPA observed the food to not be sufficiently stocked with (2) days perishable and (7) days non-perishable food. LPA was informed groceries would be brought today. The freezer did not have a sufficient supply of frozen foods, or meat. Food was observed to be wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAPPY PLACE ELDER CARE
FACILITY NUMBER: 197610100
VISIT DATE: 02/18/2025
NARRATIVE
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Cleaning supplies including detergents and pesticides and other toxins are stored in garage. Knives, sharps, and medication are observed to be kept in a locked drawer and cabinets.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. The swimming pool is appropriately fenced and was observed to be locked during visit. The garage is attached to the home and was locked and inaccessible to residents during the visit. The garage is also used as a stock room for emergency foods and PPE and laundry area.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at 119.5 F. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record; no errors noted. First aids kits have complete tools and supplies.

Client records: Client records are reviewed. Staff records: LPA conducted a complete file review of staff record. Staff #1 (S1) has no fingerprint clearance.

Citation issued, appeal rights, Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/18/2025 01:11 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 02/18/2025 at 12:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY PLACE ELDER CARE
FACILITY NUMBER: 197610100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during the physical plant inspection in the kitchen, the licensee did not comply with the section cited above, due to not having licensing requirement of (2) day persishable and (7) day non-perishable food. LPA was told the facility would be grocery shopping today. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/18/2025 01:11 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 02/18/2025 at 12:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY PLACE ELDER CARE
FACILITY NUMBER: 197610100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], and information obtained by the Administrator, resident #1 (R1) fell in January 2024, and sustained fracture. The Administrator did not submit a LIC624 to LPA or Licensing regarding the incident. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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