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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801764
Report Date: 04/29/2022
Date Signed: 04/29/2022 12:53:24 PM

Document Has Been Signed on 04/29/2022 12:53 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HAPPY HOME CARE IIFACILITY NUMBER:
565801764
ADMINISTRATOR:MICHAEL ROSALESFACILITY TYPE:
740
ADDRESS:1273 SHEFFIELD PLACETELEPHONE:
(805) 371-7801
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 4DATE:
04/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Karina AntigTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to the above facility. The LPA met with Administrator, Karina to discuss the death reporting requirement as per regulation. Entrance interview conducted.

During today’s visit, documents reviewed revealed licensee did not submit a death report (LIC 624A) for Resident #1 (R1) to Community Care Licensing (CCL). On 4/18/2022 at 6:10 p.m., the Department was notified that R1 had passed away on 4/09/2022; however, an LIC 624A was never submitted. Per interviews conducted, it was revealed that Administrator had started the death report, but did not send it to CCL. The LPA advised the Administrator that death reports are required to be reported to CCL within seven (7) days of the incident(s) as required by California Code of Regulations.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Appeal Rights discussed. A copy of the report will be provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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Document Has Been Signed on 04/29/2022 12:53 PM - It Cannot Be Edited


Created By: Martha Guzman-Chavez On 04/29/2022 at 12:24 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY HOME CARE II
FACILITY NUMBER: 565801764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2022
Section Cited
CCR
87211(a)(1)(A)

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A written report shall be submitted to the licensing agency … for the resident within seven days of the occurrence of any of (A) Death of any resident from any cause regardless of where the death occurred within seven days of the death.
This requirement is not met as evidenced by:
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The Administrator will submit death report for R1 and a Statement of Understanding, detailing how the facility will maintain in compliance of Regulation 87211 and submit to CCL by 5/06/2022.
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Based on interviews and record review, the Licensee did not ensure that R1’s death report (LIC 624A) was submitted to CCL within the seven days per regulations, which poses a potential health and safety risk to persons in care.
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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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
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