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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601151
Report Date: 04/03/2024
Date Signed: 04/03/2024 06:26:26 PM

Document Has Been Signed on 04/03/2024 06:26 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HAPPY HOMEFACILITY NUMBER:
415601151
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		ZAMORA, LOURDES R.FACILITY TYPE:
735
ADDRESS:3310 AEGEAN WAYTELEPHONE:
(650) 892-3152
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 2CENSUS: 2DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Lourdes ZamoraTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On April 3, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator and explained the purpose of today's visit.

Administrator provided a toured of the facility and grounds of this 4 bedrooms (3 upstairs and 1 downstair) and 2-story home. Common areas--living/dining room, family room, kitchen, laundry room, sun room and 2 car garage. The ground level, including office room and full bathroom. There are 3 bedrooms and 2 full bathrooms on the upper level.

LPA observed resident rooms were spacious and included all required furnishings. Three full bathrooms were observed to be clean; equipped with paper towels, soap, and non-skid mats.

LPA observed medications, toxins and sharps were locked and inaccessible to residents in care. 2 days for perishables and & 7 days non-perishable were observed to be present.

The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire drill records were reviewed.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HAPPY HOME
FACILITY NUMBER: 415601151
VISIT DATE: 04/03/2024
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LPA reviewed 2 resident records and all of them contained Admission Agreement, Medical Assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, Resident Identification information, GGRC/IPP, etc.

LPA reviewed 5 staff files and all of them contained Personnel Records, Training Records, Health Screening Records, First Aid/CPR, Criminal Record Statement, Criminal Background Clearance, etc.

During today's inspection, there are no residents present as both of them are attending the day program and school.

No deficiency cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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