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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006471
Report Date: 12/02/2025
Date Signed: 12/02/2025 12:46:25 PM

Document Has Been Signed on 12/02/2025 12:46 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
ORANGE COUNTY RO, 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: 5DATE:
12/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Aurora Tescon - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On December 2, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley introduced self and was granted entry into the facility by staff, after stating the purpose of the visit. Administrator (AD) Aurora Tecson arrived at the facility and remained to assist during the visit. Administrator Aurora Tecson has an administrator certificate that expires on July 2, 2027.

The facility is licensed to operate for six (6) non-ambulatory residents where one (1) may be bedridden in Room #1, with a hospice waiver for two (2) residents. The facility is a one-story house with four (4) resident bedrooms, two (2) bathrooms, living room, dining room, kitchen, an attached 2 car garage, and an outdoor covered seating area.

During the visit, LPA toured inside and outside of the physical plant with staff. 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 each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational with water temperatures measured between 116.7 degrees F to 117.8 degrees F.

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 a seven-day supply of non-perishable food available and maintained properly. LPA observed at least ten expired perishable items stored in the kitchen refrigerator. A deficiency is being cited.

CONTINUE TO LIC809-C.....

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
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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Document Has Been Signed on 12/02/2025 12:46 PM - It Cannot Be Edited


Created By: Eboni Bentley On 12/02/2025 at 12:07 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HAPPY HOME SENIOR CARE
FACILITY NUMBER: 306006471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the faciity did not comply with the section cited above in 1 out of 5 staff records, which poses an immediate risk to residents in care. A record review revealed S1 is cleared but not associated to the facility during today's visit.
POC Due Date: 12/03/2025
Plan of Correction
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The Administrator stated they will associate S1 to the facility and submit proof to CCLD via email by POC due date.
Type A
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility did not comply with the section cited above in 10 out of 10 perishable food item, which poses an immediate risk to persons in care. LPA observed at least 10 perishable food items being stored in the kitchen refrigerator with expiration dates that have already passed.
POC Due Date: 12/03/2025
Plan of Correction
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During visit, the administrator discarded expired food items. Administrator stated they will check food supplies weekly and provide an in service training regarding food service requirements for all staff. Administrator stated they will provide proof of training by POC due 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HAPPY HOME SENIOR CARE
FACILITY NUMBER: 306006471
VISIT DATE: 12/02/2025
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LPA toured the backyard and observed a shaded seating area with a table and chairs for residents to sit outside. The smoke detectors and carbon monoxide detectors were operable. Emergency safety drills were last conducted on September 22, 2025, and are conducted quarterly. First aid kit is maintained and contains all the necessary elements. A working telephone (657)231-9389 remains available, however, the facility does not have a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were stored in the kitchen. The facility has one (1) fire extinguisher that was charged, mounted, and last serviced on October 6, 2025. Liability Insurance is effective June 12, 2025, and expires on June 12, 2026.

LPA conducted an audit of five (5) resident files (R1-R5), five (5) staff files (S1-S5), and medication and medication administration review. Resident and staff interviews were conducted. A record review revealed one (1) out five (5) staff are not associated to the facility. A CIVIL PENALTY WAS ASSESSED.

Based on observations and record review, deficiencies are being cited during today’s inspection visit.

An exit interview was conducted, and a copy of this report, LIC809-D, LIC421BG, and appeals rights were provided to Administrator Aurora Tecson at exit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC809 (FAS) - (06/04)
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