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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700973
Report Date: 02/16/2021
Date Signed: 02/17/2021 04:15:55 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 STANSBERRYFACILITY NUMBER:
342700973
ADMINISTRATOR:SU, QUANYINGFACILITY TYPE:
740
ADDRESS:2529 STANSBERRY WAYTELEPHONE:
(916) 883-9188
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 0DATE:
02/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:SU, QUANYINGTIME COMPLETED:
04:15 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 Licensing Program Analyst (LPA) Kevin Gould conducted a component III pre licensing meeting with Licensee Quanying Su via zoom. LPA Gould and Licensee went over the component 3 powerepoint.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, Health Related Services and Conditions and Dementia Care.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files.

Exit interview was conducted. Once approved, a copy of the license will be set to the Licensee.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (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)
Page: 1 of 1