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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700973
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:07:25 PM

Document Has Been Signed on 10/14/2021 03:07 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, 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: 6DATE:
10/14/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Orlando MadridTIME COMPLETED:
03:30 PM
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On 10/14/21 at 2:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Happy Journey at Stansberry for the purpose of conducting a required Post Licensing Inspection. LPA met with Staff, Orlando Madrid and together conducted a tour of the home. LPA confirmed with staff that hospice waiver increase has been approved from two to four residents. LPA will mail a new license once information is uploaded to system.

LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA conducted file review for two staff and three residents. LPA observed all files reviewed to be complete and well organized. LPA reviewed medication administration logs and observed the logs to be complete and up to date. LPA did observe one resident is prescribed a controlled substance and LPA observed staff conduct a medication count for the controlled substance and was confirmed via medication administration log.

LPA measured the water temperature, temperature measured at 118 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. Facility is operating within compliance of regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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