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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801563
Report Date: 06/04/2026
Date Signed: 06/04/2026 12:59:24 PM

Document Has Been Signed on 06/04/2026 12:59 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 CAREFACILITY NUMBER:
565801563
ADMINISTRATOR/
DIRECTOR:		KAREN ROSALESFACILITY TYPE:
740
ADDRESS:179 NORTHAM AVE.TELEPHONE:
(818) 219-5998
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY: 6CENSUS: 3DATE:
06/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Karina Antig, Facility DesigneeTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were two (2) staff and three (3) residents present. The Assistant Administrator Karina Antig was contacted and arrived at 10:35 a.m. Entrance interview conducted.

Beginning at 11:08 a.m., the LPA, along with Assistant Administrator 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. The following was observed:

BEDROOMS: There are four (4) designated resident rooms and one (1) staff room inside the locked garage area, as well as an upstairs area solely dedicated to staff use. LPA observed the resident rooms to contain appropriate linens and furnishings.

RESTROOMS: The facility contains two (2) shared resident restrooms and one (1) staff restroom upstairs. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature initially measured slightly high, but was adjusted during today's visit. LPA will retest the water during the continuation visit.

COMMON AREAS: The common areas including the dining room and living room were observed to be properly furnished at the time of the visit. A fireplace in the living room had a screen. Two (2) fire extinguishers were observed to be fully charged and last serviced 05/20/2025. Service is scheduled. The LPA observed required postings throughout the common space. At 12:13 p.m., the hardwired combination smoke and carbon monoxide detectors were tested and all functioned properly.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
FACILITY NUMBER: 565801563
VISIT DATE: 06/04/2026
NARRATIVE
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KITCHEN: The kitchen area was observed to be adequately cleaned and appliances appeared to be functional. There was an adequate supply of perishable and non-perishable items. Knives and other sharps were observed to be locked under the kitchen sink.

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. The laundry room is in the garage locked and inaccessible. Cleaning supplies and disinfectants are kept in cabinets in the garage. There is one (1) additional refrigerator and one (1) freezer in the garage with perishable items. Facility has an adequate amount of emergency food and emergency water. Outdoor area was observed and appeared adequate for resident use. There is one gate, which does latch, but at this time was not self-closing. No residents were observed to have unsafe wandering or elopement behaviors. Assistant Administrator was advised to repair the self-latching function of the gate should the facility plan to accept any residents with unsafe wandering or elopement behaviors.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's emergency disaster plan, which was complete and updated annually as required. Disaster drills are conducted quarterly, with the last documented drill on 04/18/2026. Infection control plan will be reviewed during the continuation visit.

RECORDS/MEDICATIONS: Beginning at 11:36 a.m., LPA reviewed three (3) resident files. All resident files observed contained all required documents. Staff files will be reviewed during the annual continuation visit. Locked medication storage was observed adjacent to the kitchen, however, bubble packs with medication remaining were observed on top of a desk and in a basket underneath the desk next to the medication cabinet. Medications were not reviewed today.

During today's visit, LPA discussed the past due annual fees with the Assistant Administrator. LPA will email all invoices to Assistant Administrator, who will work with the licensee to ensure past due fees are paid.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of today's report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 12:59 PM - It Cannot Be Edited


Created By: Kelly Dulek On 06/04/2026 at 12:38 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
FACILITY NUMBER: 565801563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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, as multiple bubble packs for Resident #1 (R1) were observed out of the locked medication cabinet on top of the desk and more bubble packs containing medications were observed in a basket under the desk, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/04/2026
Plan of Correction
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Medications were removed from the desk and basket underneath the desk during the visit. Staff took the medications to the locked garage area. Staff stated they understand medications need to remain locked and apologized for leaving them out. POC cleared.
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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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