<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801563
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:20:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2024 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20240811081939
FACILITY NAME:HAPPY HOME CAREFACILITY NUMBER:
565801563
ADMINISTRATOR:KAREN ROSALESFACILITY TYPE:
740
ADDRESS:179 NORTHAM AVE.TELEPHONE:
(818) 219-5998
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY:6CENSUS: 4DATE:
08/14/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Karina AntigTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not provide resident with copy of Admission Agreement.
Licensee did not provided proper notice of rent increase to resident or responsible party.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:42 a.m., the LPA met with staff and explained the reason for the visit. At 9:56 a.m., Assistant Administrator Karina Antig arrived at the facility.

Starting at 9:56 a.m., the LPA conducted interviews with the Assistant Administrator and one (1) resident. At 10:05 a.m., the LPA conducted a resident record review. At 10:10 a.m., the LPA obtained copies of pertinent documents. At 10:36 a.m., the LPA along with the Assistant Administrator conducted a physical plant tour.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20240811081939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAPPY HOME CARE
FACILITY NUMBER: 565801563
VISIT DATE: 08/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Licensee did not provide resident with copy of Admission Agreement. On 08/11/2024, the Department received a complaint alleging that Resident #1’s (R1’s) representative did not receive a copy of the Admission Agreement within the required time frame. Per record review, R1 was admitted to the facility on 03/04/2024 and on 05/29/2024, Assistant Administrator sent the filled-out Admission Agreement to R1’s representative for review and signature via email. The LPA had several conversations with the Assistant Administrator about the importance of reviewing and signing resident records in a timely manner for accuracy and transparency. The Assistant Administrator understood and stated that moving forward all Admission Agreements will be reviewed with residents or resident representative if any and signed and dated no later than seven days following admission. The LPA reminded the Assistant Administrator that the resident or resident representative shall receive a copy of the Admission Agreement immediately upon signing and the original copy of the Admission Agreement shall be retained in the resident’s file. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations of “Licensee did not provide resident with copy of Admission Agreement” is deemed Substantiated.

Regarding the allegation: Licensee did not provided proper notice of rent increase to resident or responsible party. On 08/11/2024, the Department received a complaint alleging that Resident #1’s (R1’s) representative did not receive proper notice of rent increase to resident or responsible party. It was alleged that the rate upon admission was $4,000 however R1’s Admission Agreement listed the rate as $4,500. Per record review, R1 was admitted to the facility on 03/04/2024 and on 05/29/2024, Assistant Administrator sent the filled-out Admission Agreement to R1’s representative for review and signature via email.Due to conflicting information, the LPA could not determine if R1 required a notice for rate/ rent increase. During resident record review, Resident #2’s (R2’s) Admission Agreement, dated 01/23/2020 listed the rate for $4,000 and per interview with Assistant Administrator R2’s rate is now $4,500. The Assistant Administrator stated that the increase took place two years ago. The Assistant Administrator explained that they do not increase the rates/ rents every year and only increase the rates/ rents if necessary. The Assistant Administrator stated that she verbally communicated with R2’s representative about increasing the rate/ rent, however, written notice did not have the required 60 days notice. Per record review and interview, a notice was given for rate/ rent increase to R2's representative however not with the proper time frame. Continued on LIC 9099-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240811081939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY HOME CARE
FACILITY NUMBER: 565801563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
87507(c)
1
2
3
4
5
6
7
87507(c) Admission Agreements(c) Admission agreements shall be signed and dated, ... or the resident's representative,...& the licensee...no later than seven daysfollowing admission...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator stated that she will submit a statement of understanding and a plan on how the facility will be in compliance with the above regulation by due date.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above as R1 admissions agreement was not signed and completed within the required time frame which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
08/23/2024
Section Cited
HSC
1569.655(a)
1
2
3
4
5
6
7
1569.655 (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 60 days' prior written notice...the amount of the increase...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator stated that she will submit a statement of understanding and a plan on how the facility will be in compliance with the above regulation by due date.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the above cited section as the licensee did not provide R2’s representative a proper 60 day notice in writing including the amount of the increase, which poses a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240811081939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAPPY HOME CARE
FACILITY NUMBER: 565801563
VISIT DATE: 08/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation of “Licensee did not provided proper notice of rent increase to resident or responsible party” is deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4