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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700973
Report Date: 12/22/2023
Date Signed: 12/22/2023 04:19:43 PM


Document Has Been Signed on 12/22/2023 04:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:HAPPY JOURNEY AT STANSBERRYFACILITY NUMBER:
342700973
ADMINISTRATOR:JIAO, QIAOFACILITY TYPE:
740
ADDRESS:2529 STANSBERRY WAYTELEPHONE:
(916) 883-9188
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 6DATE:
12/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Vicky JiaoTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Vicky Jiao and explained the purpose of the visit.

LPA Moleski reviewed three resident files (R1-R3) and three staff files (S1-S3).

LPA Moleski toured the facility with Jiao and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 111 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

This facility is cleared for six ambulatory residents and five non-ambulatory residents. All six residents are non-ambulatory, according to their LIC 602s. Additionally, LPA Moleski observed both gates leading out of the back yard locked during this visit. Staff removed the locks.

LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and working smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions.

LPA Moleski interviewed two staff members (S1-S2) and two residents (R3, R5).

This facility is being cited per 22 CCR Section 87202(a). An exit interview was held with Jiao. Appeal rights and a copy of this report was left with Jiao.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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 12/22/2023 04:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: HAPPY JOURNEY AT STANSBERRY
FACILITY NUMBER: 342700973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of locks on gates leading out of the facility, and based on record review of six residents' LIC 602s, the licensee did not comply with their fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2023
Plan of Correction
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Gate locks were removed during this visit. Licensee agrees to write a plan to comply with the capacity limitations imposed by their fire clearance, which allows only five non-ambulatory residents, by the POC due date.
vincent.moleski@dss.ca.gov
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2