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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609809
Report Date: 11/09/2021
Date Signed: 11/09/2021 12:38:45 PM

Document Has Been Signed on 11/09/2021 12:38 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: 5DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karina AntigTIME COMPLETED:
12:37 PM
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
Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced visit to Happy Home Care 3 to conduct a Required 1-Year Annual Inspection with focus on Infection Control. No previous Annual has been conducted since they were pre-licensed on 11-20-2019. LPA was greeted and screened at the door by staff Catherine. Administrator Karina Antig arrived at the facility at 9:33am and was explained the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA along with Administrator Karina, initiated a tour at 9:35am and the following was observed:

There is a central entry point designated for universal screening by the entrance. At 9:46am, smoke detectors and carbon monoxide detector were tested and functioned properly at this time. Fire extinguisher was observed to be fully charged on 03-24-2021. First-Aid Kit was observed in the kitchen with the medication. Medications are in the kitchen in a locked cabinet. Main temperature displayed by hallway and read at 76 degrees Fahrenheit for the facility. LPA observed a sufficient amount of emergency food and water.



OUTDOOR SPACE: LPA observed the backyard to have a covered outdoor area with a tables and chairs for resident use. There are two (2) gates on each side of the house that have a single latch and always remains unlocked.

KITCHEN: LPA observed the kitchen/dining area to be clean. Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

(...Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 3
FACILITY NUMBER: 567609809
VISIT DATE: 11/09/2021
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
(...Continued from LIC 809...)

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and a table lamp.

RESTROOMS: LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. Water temperature was checked in two (2) resident bathrooms and are in compliance at 107.8 degrees Fahrenheit for bathroom #1- and 110.5-degrees Fahrenheit for bathroom #2.

LPA observed at least a 30-day supply of Personal Protection Equipment (PPE). The facility cleans the common areas at least twice daily. There are signs posted throughout the facility showing cough/sneeze etiquette and how to properly wash hands. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. LPA observed CDSS PINs posted by the entrance accessible to both residents and visitors.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2