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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005078
Report Date: 05/26/2023
Date Signed: 05/30/2023 08:18:22 AM

Document Has Been Signed on 05/30/2023 08:18 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 HOME 1FACILITY NUMBER:
347005078
ADMINISTRATOR:NEELAND, ANN-MARIE C.FACILITY TYPE:
735
ADDRESS:12333 CANYONLANDS DRIVETELEPHONE:
(916) 436-4531
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY: 4CENSUS: 4DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ann-Marie NeelandTIME COMPLETED:
02:45 PM
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On 05/26/22 at 12:15pm:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Happy Valley Home 1 for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Ann-Marie Neeland and together conducted a tour of the home.

LPA and Administrator 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 and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 119 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, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Client Roster

Per California Code of Regulations, Title 22 no deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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