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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609809
Report Date: 05/14/2021
Date Signed: 05/14/2021 09:27:46 PM

Document Has Been Signed on 05/14/2021 09:27 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 3FACILITY NUMBER:
567609809
ADMINISTRATOR:ROSALES, KARENFACILITY TYPE:
740
ADDRESS:191 EAST GAINSBOROUGH ROADTELEPHONE:
(805) 370-0214
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 3DATE:
05/14/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Rhodora Ilan and Michael RosalesTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPAs) Kelly Dulek and Martha Guzman Chavez visited the facility with the purpose of interviewing staff #1 (S1) in regards to complaint #29-AS-20210507143030 for another of the licensee's facilities. LPAs Dulek, and Guzman Chavez met with facility designees Rhodora Ilan and Michael Rosales. Entrance interview conducted.

LPAs interviewed S1 at 12:02PM and toured the facility with facility designee Rhodora Ilan at 12:25PM. No health and safety hazards were identified during today's visit.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
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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