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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001881
Report Date: 01/06/2023
Date Signed: 01/06/2023 03:42:03 PM


Document Has Been Signed on 01/06/2023 03:42 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:EDISON ESTATESFACILITY NUMBER:
347001881
ADMINISTRATOR:APUYA, MARY JANEFACILITY TYPE:
740
ADDRESS:3741 EDISON AVENUETELEPHONE:
(916) 484-7934
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 4DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Romeo ApuyaTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee made an unannounced visit to this facility to conduct an annual required inspection on 01/06/2023. LPAs met with Romeo Apuya and explained the purpose of today's visit. LPAs 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.

LPAs toured the facility with Romeo Apuya on 01/06/2023 at 2:25 PM.

Administrator holds current certificate and expires on 11/01/2024. The facility is licensed for 6 non-ambulatory residents, and has a hospice waiver for 1 resident. There are currently 4 residents who reside at this facility. There are no residents on hospice.

The facility has an infection control plan in place, and has covid-19 postings throughout the facility. The facility has one main screening entry point, and furniture is spaced 6 feet apart. The facility smoke and carbon detectors are in good repair. The facility fire extinguisher is in good repair. The facility has an adequate food supply and has emergency food and water kit. The facility has a first aid kit. The facility has a locked medication cabinet, and the facility does not have an updated Centrally Stored Medication and Destruction record for each resident. Moreover, resident and staff files have all the other required documents. The facility also has the required postings through out the facility. The facility is clean, but requires some wall touch ups and garbage on patio needs to be removed, and technical violation was given. The exterior emergency exits are clear of debris.

As a result of this visit, the following deficiency was cited, per California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted and 809, 809D, and appeals right were given at the end of visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/06/2023 03:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited

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87465(e)Incidental Medical and Dental Care:The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...This requirement was not met as evidence.
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Facility staff agrees to create a Centrally stored medication and destruction record for all four residents by POC Date 01/20/23. The facility staff also agrees to conduct medication training for staff by POC Date 01/20/2023.
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Based on observation, interview, and file review the facility did not have Centrally stored medication destruction record for all four residents. This posed a potential health and safety risk to residents in care.
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Training documentation will be emailed to LPA Martinez by POC Date 01/20/2023 by close of business 5PM.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
LIC809 (FAS) - (06/04)
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