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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004425
Report Date: 11/02/2023
Date Signed: 11/02/2023 11:28:59 AM

Document Has Been Signed on 11/02/2023 11:28 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 3DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Ann Marie Covarrubias)TIME COMPLETED:
11:30 AM
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On 11/2/23, Licensing Program Analyst, Kimberly Viarella made an unannounced case management visit to this facility regarding an incident report that was submitted on: 10/01/23. LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. LPA met with Ann Marie Covarvubias and a brief interview followed.

LPA was told that resident (R1) had a cast removed on 09/20/23 and that on 09/25/23 mother and staff observed swelling in R1's right foot/leg. The Administrator stated that the Doctor was notified by email and an appointment was made for 09/29/23 at 9:40 AM. On 09/26/23 PT Home Health Nurse, (N1) observed a bleeding wound on the back of R1's right heel. Staff described it as being the size of a nickel. Administrator was told that another nurse would be out to evaluate the wound. On 09/28/23, another nurse, (N2) came out and informed the Administrator that the wound was a stage 4 pressure sore. N2 instructed the Administrator to go to the scheduled orthopedic appointment and that another nurse would be out to further evaluate R1's wound. On 09/29/23, Kaiser transport was late and the Administrator and R1 arrived 20 minutes late. They were told they would need to reschedule, and they returned back to the care home.

The Administrator reported that a third nurse (N3) arrived at the care home that day and measured the wound. It was 2.5 X 2 cm and N3 confirmed it was a stage 4 pressure sore. N3 informed the Administrator that R1 should be taken to the ER for Skilled Nursing Facility transfer because the care home was not licensed to take care of the wound and the Home Health Agency was not able to provide services on a daily basis. On 9/29/23, R1 was taken to Kaiser ER in Roseville. According to the Administrator, R1's vitals were taken, R1 was seen by the physician, and then discharged. R1 went home with their responsible party (RP). On 10/02/23, the Home Health Nurse recommended R1 be taken to the ER to await for transfer into a skilled nursing facility. R1 was taken to the ER and admitted into the hospital. On 10/05/23 A bed became available at Capital Post Acute Skilled Nursing Facility and R1 was admitted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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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 VALLEY HOME
FACILITY NUMBER: 347004425
VISIT DATE: 11/02/2023
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LPA toured the facility. Other residents were not present as they were at their day programs. LPA visited R1's room and observed that it was neat and tidy, with personal items throughout. LPA learned this individual had been a resident for the past 8 years. R1 visited their responsible party after their day program on Monday and would return after program on Wednesday. These overnight visits stopped after R1 broke their leg and needed to utilize a wheelchair.

LPA interviewed 2 staff members during this visit.

Due to time constraints, this case management will be continued at a later date.

The following documents were collected/requested during this visit:

LIC 500 with contact information
LIC 601 for R1
LIC 602 for R1
IPP for R1
Discharge notes and Care Notes/Handouts from Kaiser for 10/23 - Present

No deficiencies were observed or cited during today's visit.

A copy of this report was provided.

Exit interview.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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