347004425-10-8-2025-27-AS-AVIA-DM9PQQ-20251008113132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004425
Report Date: 10/08/2025
Date Signed: 10/08/2025 11:31:50 AM

Document Has Been Signed on 10/08/2025 11:31 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 HOME		FACILITY NUMBER:	347004425
ADMINISTRATOR/ DIRECTOR:	ANNMARIE C COVARRUBIAS		FACILITY TYPE:	735
ADDRESS:	12349 EDYTH LAKE WAY		TELEPHONE:	(916) 534-7911
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95742
CAPACITY: 4		CENSUS: 3	DATE:	10/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:14 AM
MET WITH:	Ann-Marie Covarrubias Neeland		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/8/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA initially met with staff on duty (S1 & S2) and stated the purpose of the visit. The Administrator Ann-Marie Neeland (AD), was notified and arrived shortly after. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 4 adult residents, ages 18 to 59, all ambulatory only. Facility is also vendored by Alta California Regional Center. Initial Observation: Upon arrival LPA did not observe any residents during this visit. Per interview with S1, residents were out in the community. LPA observed required posters and facility license at the entrance. Room temperature was at 75 degrees Fahrenheit upon arrival. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. Facility has 4 resident bedrooms and two resident bathrooms, and one staff room. Per observation of resident bedrooms: one bedroom is currently unoccupied; bedrooms are in good repair; LPA observed required furniture and sufficient lighting throughout. Per observation of bathroom: one bathroom in the hallway and the other is located in the master bedroom; both bathrooms were observed to be in good repair; hot water temperature was taken in the hallway bathroom and was measured at 107 degrees Fahrenheit. {1 of 2}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 10/08/2025

NARRATIVE

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Per observation of the kitchen and food supplies: kitchen was observed to be clean and sanitary; refrigerator and freezer were observed to be maintained at regulatory temperature; sharp objects, cleaning supplies and other dangerous items were in locked storage and not accessible to residents; facility maintains at least 2-day perishable and 7-day nonperishable food supplies; fire extinguisher is located in the kitchen area and was last inspected on 6/2/25.
Outdoor area was inspected: LPA observed outdoor furniture for resident use. Emergency walkways were observed to be unobstructed; part of the exit gate (garage side) was observed to be wobbly; advisory was provided to have the gate repaired.

Record Reviews:
Review of 3 of 3 resident files (R1, R2, R3) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status.
Medication review of 2 residents (R1, R2) include review of physician orders for over-the-counter medications. Resident cash was also reviewed for 2 residents (R1, R2). S1 counted the money on hand. No issues were noted at this time.
Review of 3 staff files (S1, S2, AD) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time.
LPA also reviewed fire drill/disaster drill records; facility conducts monthly drill. Advisory was provided to AD to conduct training with staff regarding the location of shut-off valves and how to operate during emergency situation.
LPA was provided a copy of current Liability Insurance Certificate, LIC500 , LIC308, Resident Roster, and Surety Bond during this visit.

Interviews:
LPA interviewed 2 staff. No resident in care during this visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. Exit interview was conducted with AD. A copy of the report was provided upon exit.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

LIC809 (FAS) - (06/04)

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