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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700973
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:38:14 PM

Document Has Been Signed on 12/20/2024 12:38 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/
DIRECTOR:		JIAO, QIAOFACILITY TYPE:
740
ADDRESS:2529 STANSBERRY WAYTELEPHONE:
(916) 883-9188
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Qiao 'Vicky' JiaoTIME VISIT/
INSPECTION COMPLETED:
12:45 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 six resident files (R1-R6) and three staff files (S1-S3). LPA Moleski observed that R6 is bedridden, according to their most recent LIC 602, dated 3/9/24. R4's most recent LIC 602, dated 12/13/24, indicates that they are non-ambulatory. A prior LIC 602 dated 11/25/24 indicated that R4 was bedridden. Jiao said that R4 currently needs to be turned and repositioned in bed to prevent bed sores. Health and Safety Code Section 1569.72(b)(1) defines a bedridden resident as one "requiring assistance in turning and repositioning in bed." This facility is cleared for six non-ambulatory residents, and is not cleared to accept or care for any bedridden residents.

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 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 115 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/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 closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S2) and one resident (R5). This facility is hereby cited per 22 CCR Section 87202(a)(2). An immediate civil penalty in the amount of $500 is hereby assessed due to a fire clearance violation. An exit interview was held with Jiao. Appeal rights and a copy of this report were left with Jiao.
Stephen RichardsonTELEPHONE: (916) 263-4746
Vincent MoleskiTELEPHONE: (559) 365-5294
DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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Document Has Been Signed on 12/20/2024 12:38 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: 12/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, bedridden residents were retained without the appropriate fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2024
Plan of Correction
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Licensee agrees to provide a written plan of correction by 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.
Stephen RichardsonTELEPHONE: (916) 263-4746
Vincent MoleskiTELEPHONE: (559) 365-5294

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024

LIC809 (FAS) - (06/04)
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