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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801764
Report Date: 02/01/2024
Date Signed: 02/01/2024 04:45:12 PM

Document Has Been Signed on 02/01/2024 04:45 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
WOODLAND HILLS N.ASC, 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: 5DATE:
02/01/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Karina Rosales Antig-Co AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 01/19/2024. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Karina Rosales Antig arrived shortly.

Today the LPA conducted a medication audit, staff interviews and finished the record review initiated on 1/19/2024.

Record Review: The LPA observed documentation for Disaster prevention and last fire drill (conducted on 12/18/2023). The LPA obtained Resident and Staff Rosters. The LPA observed five (5) out of (5) staff files. Two (2) out of five (5) staff were missing 6 hours of medication training, 4 hours of dementia training, 1 hour of general topics training and 2 hrs of Postural supports and and restricted health conditions. One (1) out of five (5) staff files was observed to be missing all annual training required.

Medications: At 3:45 p.m. a medications review was initiated for two out of five residents. Medications are centrally stored and locked in a locked cabinet in the dining area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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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Document Has Been Signed on 02/01/2024 04:45 PM - It Cannot Be Edited


Created By: Esther Cortez On 02/01/2024 at 04:17 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: 02/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility did not have an Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee agreed to develop and complete an infection control plan and submit the plan to CCL by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Licensee agreed to provide training for the three staff in the required topics for the 20 hour annual training and submit to CCL 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/01/2024 04:45 PM - It Cannot Be Edited


Created By: Esther Cortez On 02/01/2024 at 04:27 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: 02/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1569.69(b)
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in three out of five staff which poses a potential health and safety risk to residents in care
POC Due Date: 02/15/2024
Plan of Correction
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The Administrator agreed to do the following:
1. Complete the 8 hours of annual medications training for three staff. Submit proof by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024


LIC809 (FAS) - (06/04)
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