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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004425
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:41:19 PM

Document Has Been Signed on 09/12/2024 03:41 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 VALLEY HOMEFACILITY NUMBER:
347004425
ADMINISTRATOR/
DIRECTOR:
ANNMARIE C COVARRUBIASFACILITY TYPE:
735
ADDRESS:12349 EDYTH LAKE WAYTELEPHONE:
(916) 534-7911
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY: 4CENSUS: 3DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Annmarie CovarrubiasTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA Valerio met with facility staff Merle, and explained the purpose of the visit. LPA Valerio was later met by Administrator Annmarie Covarrubias.

LPA Valerio and facility staff toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed LPA Valerio observed common areas to be clean, organized, and free from debris. Kitchen area was clean and organized. LPA observed two days of perishable food items and seven days of non-perishable food items. Fire extinguisher, pull alarm system, carbon monoxide detectors, and air conditioning were observed to be in working condition. Resident bedrooms were observed to be clean, free from odors, fully furnished, and organized. Resident bathrooms were observed to be clean and fully stocked. Hot water was measured within regulatory range of 105-120.0 degrees F. The temperature inside the facility was 71 degrees F. The backyard was observed to have areas for outdoor activities and areas for sitting. No emergency exits were obstructed. Residents were observed arriving from Day Program/School, conducting activities with staff, eating snacks, watching television, and playing on their phone. Staff were observed cleaning up from lunch, assisting residents once home, conducting activities with residents, and preparing dinner.

LPA Valerio reviewed two (2) staff files and three (3) resident files. Resident files were observed to be complete with required annual documentation. Staff files were up to date with required training.

LPA Valerio requested the following documentation be sent to Regional Office: LIC 500, LIC 308, LIC 610, and copy of Surety Bond.

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited on today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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