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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006471
Report Date: 10/23/2024
Date Signed: 10/23/2024 10:29:55 AM

Document Has Been Signed on 10/23/2024 10:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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:
10/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:17 AM
MET WITH:Thomas Vu - Administrator, Tina Vu - ManagerTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of
conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by
designated Administrator (AD) Thomas Vu and Manager (M) Tina Vu. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on 12/13/2023.

The facility is a one-story home with four resident bedrooms, two resident bathrooms, common area, kitchen, backyard and an attached two car garage. The back yard has two exit gates on one both sides of the house and two shaded seating areas. There is a second unit on the property that houses 3 bedrooms and 2 bathrooms. AD stated that he, his wife and his son will be living back there and that it is not part of the facility. The back house also has a different address than the facility address. All resident bedrooms had the required furnishings and ample lighting. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. All and any toxic chemicals are inaccessible to residents and will be stored and locked in the garage. Medication, First Aid Kit and Manual are stored in a locked closet near the entryway. The first aid kit has all the required elements. Fire extinguishers are fully charged and was purchased on 11/11/2023 as indicated by the receipt. The facility has books, magazines, a piano and televisions for resident activities. Fire clearance was approved by a fire inspector of Fountain Valley Fire Department on 6/4/2024. Component III was conducted. All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 105-120 degrees Fahrenheit in the three resident bathrooms. Resident bathrooms also have shower mats in showers. Emergency Phone Numbers, Exit Plan & Menu are posted and available for review. Smoke detectors and carbon monoxide detectors tested operational. Appliances are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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