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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701259
Report Date: 04/22/2024
Date Signed: 04/22/2024 02:00:45 PM

Document Has Been Signed on 04/22/2024 02:00 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 HEARTS CARE HOME, INC.FACILITY NUMBER:
392701259
ADMINISTRATOR/
DIRECTOR:
EMPERADOR, ANN KRISTINEFACILITY TYPE:
735
ADDRESS:671 SANDPIPER CIRCLETELEPHONE:
(916) 833-6978
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 4CENSUS: 1DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:54 PM
MET WITH:Ann Kristine Emperador TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 04/22/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Ann Kristine Emperador and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for 4 ambulatory clients, which one client can be non-ambulatory and reside in bedroom one. There is currently one client who resides at this facility.

The LPA Martinez toured the facility with Ann Kristine Emperador on April 22, 2024 at 1:30 PM.

LPA Martinez reviewed one resident file and one staff file, and the files were maintained. The facility has a disaster preparedness plan and infection control plan. LPA Martinez reviewed one resident medication file and Medication Administration Record was complete and maintained. The facility has a first aid kit. The facility smoke detectors, carbon detectors, and fire extinguishers are in good repair. The exterior emergency gate is in good repair. The facility has an adequate food supply, and the facility kitchen is in good repair. The facility temperature measured at 71 degrees, and the water temperature measured at 109 degrees.

Based on this annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


An exit interview was conducted, and a copy of this report was given to the facility at the end of the visit.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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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