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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006471
Report Date: 08/19/2024
Date Signed: 08/26/2024 01:47:51 PM

Document Has Been Signed on 08/26/2024 01:47 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:HAPPY HOME SENIOR CAREFACILITY NUMBER:
306006471
ADMINISTRATOR/
DIRECTOR:		VU, THOMASFACILITY TYPE:
740
ADDRESS:11142 LAVENDER AVENUETELEPHONE:
(714) 398-3318
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 0DATE:
08/19/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Thomas Vu, Administrator
Tina Vu, Applicant		TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Component II completion: Unsuccessful

Facility Type: Residential Care Facility for the Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): None
COMP II Participants: Thomas Vu, Administrator
Tina Vu, Applicant
Interview Method: Telephone interview

On August 19, 2024 and August 26 2024, applicant and administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During the COMP II, applicant and administrator did not provide sufficient knowledge of the program and/or community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Component II will be rescheduled.

Exit interview conducted with applicant and administrator. Report sent via email and request to return sign copy to CAB by end of business day today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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