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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310302384
Report Date: 05/04/2023
Date Signed: 05/05/2023 08:41:44 AM


Document Has Been Signed on 05/05/2023 08:41 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 14DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tito Andrada, Jr.TIME COMPLETED:
05:00 PM
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LPA Tryon visited the facility on 5/4/2023 to do an annual visit using the CARE Tool. LPA met with Tito Andrada and Tito Andrada Jr.
LPA toured the facility including common areas, kitchen, bedrooms, restrooms, hallways, storage, garage, yard. The facility consists of several buildings. Two of the buildings are resident areas. The large back building has a very large central common area, with 4 double bedrooms and bathrooms. The front house includes kitchen, dining room, living room, 4 client bedrooms, bathrooms, storage, small office/medication room. A third building includes laundry.
The facility appears to be clean, nicely furnished. Smoke detectors/sprinklers/alarm system installed. Carbon monoxide detectors installed. Fire extinguishers present and charged.
Food supplies were viewed and are adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies. Medications are centrally stored and locked, sharp knives are locked, as well as other hazardous items.
LPA reviewed the CARE Tool with staff.
LPA interviewed one staff and 2 residents.

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) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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