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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 310302384
Report Date: 02/28/2024
Date Signed: 02/29/2024 09:48:13 AM


Document Has Been Signed on 02/29/2024 09:48 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 13DATE:
02/28/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Tito Andrada, Jr.TIME COMPLETED:
04:00 PM
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LPA Tryon visited Mr. Andrada at the facility in order to have him sign an Annual Review for another home. When LPA did the visit on that date, the computer power died; and LPA did not have a power cord on the visit.

No issues were cited at this home.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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