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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609809
Report Date: 11/17/2022
Date Signed: 11/17/2022 06:08:21 PM

Document Has Been Signed on 11/17/2022 06:08 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:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Karina Rosales Antig, StaffTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Annual Inspection with focus on Infection Control.

LPA was greeted and screened at the door by staff. Reason for visit was explained. LPA and staff toured the physical plant areas inside and outside to ensure facility is in compliance with Title 22 Regulations.

Following was observed:

There is a central entry point designated for universal screening by the entrance. 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. Sufficient supply of Personal Protection Equipment observed. Fire and carbon dioxide alarms tested and observed functioning properly. During the tour LPA observed four resident room exit doors leading to the backyard with child safety lock.



Pursuant to Title 22, Division 6, following observed deficiency was observed and cited (see 809D).

Exit interview conducted. Copy of the report issued via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 11/17/2022 06:08 PM - It Cannot Be Edited


Created By: Zabel Chochian On 11/17/2022 at 01:31 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 3
FACILITY NUMBER: 567609809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468(a)(6)
Personal Rights. Each resident shall have the right to leave the facility at any time and to not be locked into any room, building or on facility premises by day or night.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Four out of five resident room exit doors observed with safety (child locks) installed. This poses an immediate personal rights risk to persons in care.
POC Due Date: 11/17/2022
Plan of Correction
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Maintinance staff removed the safety locks from resident room exit doors (leading to the backyard) during visit today. Assistant Administrator Karina Rosales Antig acknowledged understanding of section cited.
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:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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