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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320424
Report Date: 07/28/2025
Date Signed: 07/28/2025 07:15:40 PM

Document Has Been Signed on 07/28/2025 07:15 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HAPPY LIFE ELDER CAREFACILITY NUMBER:
198320424
ADMINISTRATOR/
DIRECTOR:		DIONISIO, ANTONIA E.FACILITY TYPE:
740
ADDRESS:22002 NEPTUNE AVENUETELEPHONE:
(310) 435-5820
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 5DATE:
07/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:21 PM
MET WITH:ANTONIA DIONISIO TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On July 28, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with licensee/administrator Antonia Dionisio and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents (1) may be bedridden and (3) non-ambulatory ages 60 and above. The facility is approved for (4) hospice residents.Currently, the facility has (3) residents in hospice care.

The facility consists of five (5) bedrooms, (1) staff bedroom, two (2) bathrooms, (1) staff bathroom a one story home with a one (1) car garage, a living area, a dining area, a kitchen, and an outside seating area.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 112.7 degree F. A comfortable temperature of 77 degree F. was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly.
Evaluation Report Continues LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2025
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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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HAPPY LIFE ELDER CARE
FACILITY NUMBER: 198320424
VISIT DATE: 07/28/2025
NARRATIVE
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Fire extinguisher was charged, smoke detectors and carbon monoxide were operable. The last fire drill conducted on 07/04/25. A review of the Medication Administration Record (MAR) was complete and accurate. A landline telephone was in working condition.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained.The facility has current liability insurance on file effective 03/27/25 03/27/26 policy #0100359573-0 . The facility is current on Community Care Licensing annual dues. An audit of residents #1-#6 (R1-R5) service files were complete and staff #1-#5 (S1-S5) personnel files were partially complete.

Deficiencies:
LPA observed that the centrally stored medications for Resident #1 were not kept in a secure, locked location, making them accessible to the residents in care. Additionally, Staff #1 and Staff #2 did not have their Health Screen records on file. Furthermore, Staff #4 and Staff #5 had not completed the required initial training, and there were no records to confirm this.

An exit interview conducted with Antonia Dionisio and a copy of report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/28/2025 07:15 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/28/2025 at 03:34 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAPPY LIFE ELDER CARE
FACILITY NUMBER: 198320424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
97465(h)(2)
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed (3) medication for (R1) not securely locked and kept in a safe storage. LPA found (3) (1) Brimodindine and (2) Timolol Maleate medications on the dining room table. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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Licensee will ensure that all medications be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. LIcensee will store medicatons for R1 in locked cabinet. Proof of correction must be sent to LPA Dabuet at ernand.dabuet@dss.ca.gov
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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2025 07:15 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/28/2025 at 03:42 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAPPY LIFE ELDER CARE
FACILITY NUMBER: 198320424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(3)(A-F)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(3) The training shall include, but not be limited to, the following:
(A) The aging process and physical limitations and special needs of the elderly.
(B) Importance and techniques of personal care services, including but not limited to, bathing, grooming, dressing, feeding, toileting, and infection control, as specified in Section 87470, Infection Control Requirements.
(C) Residents rights, as specified in Section 87468, Personal Rights.
(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection.
(E) Psychosocial needs of the elderly, such as recreation, companionship, independence, etc.
(F) Recognizing signs and symptoms of dementia in individuals.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the licensee did not comply with the section cited above. LPA identified staff #4 & staff 5 did not initial required annual training. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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Licensee will adhere to Title 22 regulations 87411 and shall have intial required training for both staff #4 and #5 completed by due date 08/18/25. Proof of correction must be sent to LPA Dabuet at ernand.dabuet@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2025 07:15 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/28/2025 at 03:57 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAPPY LIFE ELDER CARE
FACILITY NUMBER: 198320424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(2)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

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. LPA identified staff #1 and staff #2 did not have health screening records on file and no TB test results. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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Licensee will adhere to Title 22 87412 and ensure that all employees have a Health Screening LIC 503 on file with TB test results. Proof of correction must be sent to LPA Dabuet by 8/18/25 by email ernand.dabuet@dss.ca.gov
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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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