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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005078
Report Date: 07/23/2024
Date Signed: 07/23/2024 12:52:55 PM

Document Has Been Signed on 07/23/2024 12:52 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 HOME 1FACILITY NUMBER:
347005078
ADMINISTRATOR/
DIRECTOR:		NEELAND, ANN-MARIE C.FACILITY TYPE:
735
ADDRESS:12333 CANYONLANDS DRIVETELEPHONE:
(916) 436-4531
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY: 4CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Myrna CarilloTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 07/23/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator (DFA). LPA met with Designee, Myrna Carillo and a brief interview followed.

LPA inspected 4 resident rooms. All had the required furniture, furnishings and lighting to be in compliance at the present time. Each resident's door also had a lock to provide privacy. LPA also viewed staff break room as depicted on facility sketch.

The LPA inspected the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. All foods in the refrigerator and freezer were packaged and dated appropriately. The fire extinguisher was last serviced on 06/04/24 by River City Fire Extinguisher Company and was in compliance at the time of inspection.

LPA inspected a total of 2 bathrooms. Each contained soap, paper towels, and trash cans with lids as required. Hot water was measured to ensure the temperature was between 105 and 120 degrees Fahrenheit in order to be in compliance. Hot water measured 114.2 degrees Fahrenheit.

The LPA observed medications were stored in a locked closet in the kitchen and inaccessible to residents in care. Medications were primarily the pill packs. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance.

The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. There were also a sitting area with shade in the rear of the house for residents to enjoy.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 1
FACILITY NUMBER: 347005078
VISIT DATE: 07/23/2024
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LPA observed an activity calendar, sample menu, facility license, IF YOU SEE SOMETHING, SAY SOMETHING sign, along with resident rights posters.

LPA conducted a sample file review. LPA reviewed 3 resident files and 3 staff files and all were in compliance at the present time. LPA also compared staff roster to Guardian roster to ensure background checks had been completed. All were in compliance at the present time.

According to California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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