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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700648
Report Date: 10/05/2023
Date Signed: 10/12/2023 02:28:57 PM


Document Has Been Signed on 10/12/2023 02:28 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:HAPPY JOURNEY CARE HOME, LLCFACILITY NUMBER:
342700648
ADMINISTRATOR:SU, QUANYINGFACILITY TYPE:
740
ADDRESS:4728 JOHNSON DRIVETELEPHONE:
(415) 734-6836
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Saturnina Daroy Tamayo, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 10/05/23 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA spoke with Administrator, Qiao Jiao, via telephone call. Administrator stated that they could not attend visit and gave permission for caregiver, Saturnina Daroy Tamayo, to sign report.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six bedrooms and six bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 115.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy. LPA also requested a staff roster and updated emergency disaster plan during inspection.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87309(a) regarding chemicals being accessible to residents. Deficiency is listed on 809-D.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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


Document Has Been Signed on 10/12/2023 02:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: HAPPY JOURNEY CARE HOME, LLC
FACILITY NUMBER: 342700648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the facility did not ensure that chemicals were locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Facility moved chemicals to a locked area during inspection. LPA cleared deficiency at the conclusion of today's inspection.
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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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