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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804293
Report Date: 03/13/2025
Date Signed: 03/13/2025 02:27:10 PM

Document Has Been Signed on 03/13/2025 02:27 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HAPPY VILLAGE LIVINGFACILITY NUMBER:
486804293
ADMINISTRATOR/
DIRECTOR:		MORALES, GLORIAFACILITY TYPE:
740
ADDRESS:1564 NIGHTFALL LNTELEPHONE:
(707) 637-6458
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
03/13/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Gloria Morales, Licensee/ApplicantTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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At approximately 10:50 AM, Licensing Program Analyst (LPA) Julie Florio arrived announced to conduct a pre-licensing inspection and was greeted by Licensee/Applicant, Gloria Morales. This pre-licensing inspection is being conducted for an initial licensing of an Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for 6 ambulatory residents. Facility does not currently have a dementia care plan or Hospice waiver. Licensee/Applicant is not currently in partnership with North Bay Regional Center (NBRC) or a placement agency but plans to look into this. Licensee/Applicant does not plan to advertise until after receiving license.

At approximately 11:25 AM, LPA initiated a tour of the facility and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed resident showers with the required non-slip mats and grab bars in place. LPA observed a supply of clean linens, hygiene products, and paper products available for residents. Facility has five bedrooms with one downstairs and four upstairs. Residents' bedrooms have the appropriate furnishings as outlined in Title 22 regulations. However, each was missing a chest of drawers, but the licensee ordered one for each bedroom during today's inspection. Licensee also ordered night lights for the hallways and common areas during today's inspection.

There are dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in various designated drawers and cabinets as well as under the locked kitchen sink. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Licensee/Applicant agrees to keep keys to these items secured and inaccessible to residents in care, possibly by installing key pads.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HAPPY VILLAGE LIVING
FACILITY NUMBER: 486804293
VISIT DATE: 03/13/2025
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...continued from LIC809...

Facility has perishable foods and will purchase more upon licensure and obtaining residents. Facility has a least one week of non-perishable foods and an emergency water supply.

Licensee will post a sample menu in the common area to indicate a healthy and balanced set of meals for residents in care. The facility has a land line with a phone on the way, has an internet access device designated for resident use and has internet services. Facility has a designated locked closet for centrally stored medications and resident, staff, and facility files. LPA observed the facility's infection control plan, first aid kits, PPE, other emergency supplies, and games and activities available for resident use. Licensee will post an activity schedule in the facility.

Facility has two fire extinguishers, which were last inspected 1/2025 and are fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Licensee/Applicant has posted hard copies of the administrator's certification, emergency disaster plan and maps, personal rights information, and reporting posters in facility communal areas. LPA informed Licensee/Applicant that visiting hours shall be posted as well. Licensee/Applicant does not currently have any staff associated to facility but will hire and associate staff upon licensure. Licensee has been informed of association and staff transfer process.

The backyard features paved walkways and a patio with a shaded seating for resident outdoor use. Windows, screens, and blinds are all found to be in good repair.

Licensee/Applicant submitted a copy of the facility's lease agreement to the Centralized Application Bureau and will submit proof of liability insurance once plan is active post licensure. LPA observed a facility sketch which accurately reflects the floor plan.

Component III orientation was conducted with the Licensee/Applicant at facility where they conveyed knowledge and understanding of Title 22 regulations. The pre-licensing evaluation has been completed.

Exit interview conducted with Applicant, whose signature on this document confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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