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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004425
Report Date: 07/28/2022
Date Signed: 07/28/2022 10:54:33 AM

Document Has Been Signed on 07/28/2022 10:54 AM - 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 VALLEY HOMEFACILITY NUMBER:
347004425
ADMINISTRATOR:ANNMARIE C COVARRUBIASFACILITY TYPE:
735
ADDRESS:12349 EDYTH LAKE WAYTELEPHONE:
(916) 534-7911
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY: 4CENSUS: 4DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Vilma FranciscoTIME COMPLETED:
11:30 AM
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On 7/28/22 at 9:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Happy Valley Home for the purpose of conducting a required 1 year annual inspection. LPA met with Staff, Vilma Francisco and together conducted a tour of the home.

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 . LPA observed the hallway bathroom light-switch is not functioning as designed and is no longer operational and will not turn on one of the bathroom lights. There is sufficient light in the bathroom but the switch should be repaired as soon as possible. LPA observed one large branch on the trees in the back yard that has has broken off from the tree and needs to be removed. LPA also advises to cut one of the dead tree branches to ensure they do not fall on a resident while in the back yard.

LPA measured the water temperature, temperature measured at 106 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.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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