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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310302384
Report Date: 05/18/2022
Date Signed: 05/19/2022 09:34:25 AM


Document Has Been Signed on 05/19/2022 09:34 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:EDGEWOOD GUEST HOMEFACILITY NUMBER:
310302384
ADMINISTRATOR:ANDRADA, T. AND R.FACILITY TYPE:
740
ADDRESS:1361 MARTIN DRIVETELEPHONE:
(530) 885-9613
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:15CENSUS: 15DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Tito Andrada, Jr.TIME COMPLETED:
05:00 PM
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.LPA Tryon visited the facility on 5/18/22 to do an annual inspection using the Infection Control Domain of the CARES Tool. LPA met with Administrator Tito Andrada, Jr.

LPA toured all parts of the home including common areas, kitchen, dining room, bedrooms, bathrooms, hallways, storage areas, yard and patio. The home has adequate food supplies, household supplies, etc. Smoke detectors installed and functioning; the facility is equipped with fire sprinklers.

The house and furnishings appear to be clean and in good condition.

LPA reviewed the Infection Control Domain of the CARES Tool with the Administrator.

At this time, the facility appears to be in substantial compliance with the regulations. No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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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