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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701259
Report Date: 05/10/2023
Date Signed: 05/10/2023 10:05:50 AM

Document Has Been Signed on 05/10/2023 10:05 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HAPPY HEARTS CARE HOME, INC.FACILITY NUMBER:
392701259
ADMINISTRATOR:EMPERADOR, ANN KRISTINEFACILITY TYPE:
735
ADDRESS:671 SANDPIPER CIRCLETELEPHONE:
(916) 833-6978
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 4CENSUS: 0DATE:
05/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ann Emperador, AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Renee Campbell conducted an announced pre-licensing inspection and met with Ann Emperador, Administrator and Licensee.

LPAs toured the clients bedrooms, bathrooms, dining rooms, common living areas, kitchen, and backyard. There is sufficient lighting around the facility. Client rooms are equipped with the proper furniture and lighting. Client's rooms have proper bedding and linens for the client's to use. The kitchen was observed cleaned and within compliance. Bathrooms were equipped with grab bars and hygiene items. Living room is equipped with the proper furniture for the clients. All toxins and sharp objects are locked. Passageways and hallways are free of obstruction. Fire extinguisher is in compliance. Smoke detectors and Carbon Monoxide detector are equipped around the facility. Medication cabinet has a lock and first aid kit is complete. Hot water temperature is measured at 116 degrees Fahrenheit. This is an new facility and 2-day perishable and 7-day nonperishable are available for the clients.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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