347001881-1-13-2022-27-AS-AMAZ-CAMUF3-20220113143203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001881
Report Date: 01/13/2022
Date Signed: 01/13/2022 02:32:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	EDISON ESTATES		FACILITY NUMBER:	347001881
ADMINISTRATOR:	APUYA, MARY JANE		FACILITY TYPE:	740
ADDRESS:	3741 EDISON AVENUE		TELEPHONE:	(916) 484-7934
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	6	CENSUS: 6	DATE:	01/13/2022
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Emma Bautista		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 01/13/2022. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

LPA Martinez toured the facility with Emma Bautista on 01/13/2022 at 1:30 PM.

Administrator holds current certificate and expires on 11/01/2022. The facility is licensed for 6 non-ambulatory residents, and has a hospice waiver for 1 resident. There are currently 6 residents who reside at this facility. There are no residents on hospice.

The facility is sanitary and furnished. The facility is conducting hourly disinfecting cleaning. Common furniture is spaced 6 feet apart. The facility has implemented social distancing practices. The facility has a 30 day supply of PPE. The facility has Covid-19 posters throughout the facility. The facility has one main screening entry point. The facility conducts family visit outside and also provides virtual visits. Fire extinguishers are in good repair. Smoke and carbon detectors are in good repair.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.

Exit interview was held, and a copy of this report was given to the facility

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

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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