342700973-2-17-2021-27-AS-KGOD-BYC2BP-20210217161527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700973
Report Date: 02/16/2021
Date Signed: 02/17/2021 04:15:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	HAPPY JOURNEY AT STANSBERRY		FACILITY NUMBER:	342700973
ADMINISTRATOR:	SU, QUANYING		FACILITY TYPE:	740
ADDRESS:	2529 STANSBERRY WAY		TELEPHONE:	(916) 883-9188
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95826
CAPACITY:	6	CENSUS: 0	DATE:	02/16/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Licensee, Quanying Su		TIME COMPLETED:	04:00 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	On 2/16/21 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould conducted a tele-prelicensing inspection and Component 3 meeting for Happy Journey at Stansberry (RCFE). LPA Gould met with Licensee Quanying Su and together conducted the inspection and component 3. The Licensee is requesting a capacity of six (6) LPA observed the approved fire clearance is for six (6) residents, up to five (5) may be non-ambulatory. The home is located in a residential area with 6 bedrooms, 1 1/2 bathrooms, living room, dining room, family Bonus room, kitchen, laundry room, backyard. Bedroom #1: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #2: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #3: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #4: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #5: Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #6 Vacant, to be occupied by one (1) resident. LPA observed one twin bed, adequate storage and lighting. Smoke detector is working and operational. Bathroom #1: LPA and observed bathroom #1 is a half bathroom equipped with toilet and sink with appropriate grab bars. Bathroom #2: is a full bath with toilet, sink and roll in shower with appropriate grab bars.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HAPPY JOURNEY AT STANSBERRY	FACILITY NUMBER: 342700973
	VISIT DATE: 02/16/2021

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LPA observed adequate seating for residents in the kitchen and an appropriate number of plates, cups and silverware to meet the residents needs. Licensee has an appropriate supply of non-perishable food supply and a 2 day supply of fresh perishable foods. LPA observed the medication storage closet in hallway locked in accordance with Title 22 regulations. LPA also observed sharp knives locked in a drawer in the kitchen and cleaning supplies locked in laundry room. the same storage area. the facility has a working fire extinguisher and fully stocked first aid kit.

Facility will not transport residents in a facility vehicle or personal vehicle.

An exit interview was conducted with the licensee and a copy of this report was mailed to the facility for signature. Facility meets regulations to proceed with licensure pending application review.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC809 (FAS) - (06/04)

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