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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610100
Report Date: 03/23/2026
Date Signed: 03/23/2026 01:36:09 PM

Document Has Been Signed on 03/23/2026 01:36 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.RO, 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: 5DATE:
03/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 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 was greeted by caregiver Lirio Imperio and informed her the reason of the visit. Administrator Herman Javier was contacted and also explained the reason for the visit, who arrived during the annual inspection.

A tour of the physical plant was conducted: The facility has seven (7) bedrooms, with (1) room for staff, and and three (3) bathrooms. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and observed to be clean. Living and dining room furniture were also checked. The living room is neat and clean along with dining. The facility maintains a comfortable temperature. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguisher was located in the kitchen and observed to be filled and current. Residents rooms are adequately furnished with appropriate linens and bedding. There is sufficient amounts of personal hygiene product which is provided by the licensee. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean. Cleaning supplies including detergents and pesticides and other toxins are stored in garage. Knives and sharps are observed to be kept in a locked drawer in the kitchen. 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. No bodies of water or swimming pool, which has been cemented and covered up. The garage is also used as a stock room for emergency foods and PPE and laundry area.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAPPY PLACE ELDER CARE
FACILITY NUMBER: 197610100
VISIT DATE: 03/23/2026
NARRATIVE
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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 a range of 110.7°F degrees. There is enough clean linen available.

Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies.

Client records: Client records are reviewed, Residents 1-3, were missing needs and service plans, and R1 & R3 missing pre-admission appraisals. R2 did not have a complete medical assessment. Staff records: LPA conducted a complete file review of staff record. Staff #1 & 2 were missing first aid/CPR training certificates and yearly training. LPA observed current training for 2026.

Disaster drill was last conducted on November 2025.

Citations issued, appeal rights, exit interview and copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/23/2026 01:36 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 03/23/2026 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: 03/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above in [2] out of [2) staff did not have current first aid/CPR training and certificates which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2026
Plan of Correction
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The Administrator agreed to email LPA 03/24/2026 by COB the dates when staff 1 & 2 are scheduled to complete CPR training. Once the date has been emailed to LPA, the Administrator will submit the completed CPR training and certificates to LPA.
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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/23/2026 01:36 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 03/23/2026 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: 03/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above in [2] out of [2] record reviews for staff 1 & 2 did not have yearly training records for the year 2025. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2026
Plan of Correction
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POC is cleared, LPA observed current (20) hours of 2026 training records that started 01/10/2026.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above in [2] out of [2] record reviews for staff 1 & 2 did not have yearly training records for the year 2025. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2026
Plan of Correction
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POC is cleared, LPA observed current (20) hours of 2026 training records that started 01/10/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/23/2026 01:36 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 03/23/2026 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: 03/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above in [2] out of [2) staff did not have current first aid/CPR training and certificates which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2026
Plan of Correction
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The Administrator agreed to email LPA 03/24/2026 by COB the dates when staff 1 & 2 are scheduled to complete CPR training. Once the date has been emailed to LPA, the Administrator will submit the completed CPR training and certificates to LPA.
Type B
Section Cited
CCR
87506(b)(10)
Resident Records
(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above in [1] out of [3], R2 is missing a complete physician report, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2026
Plan of Correction
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Administrator will a completed physician for resident # 2 by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


LIC809 (FAS) - (06/04)
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