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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001881
Report Date: 12/20/2023
Date Signed: 12/20/2023 12:23:52 PM


Document Has Been Signed on 12/20/2023 12:23 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary Jane ApuyaTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady made an unannounced visit to this facility to conduct an annual required inspection on 12/20/2023. LPA met with Mary Jane Apuya and explained the purpose of today's visit. LPA 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 toured the facility with Mary Jane Apuya on 12/20/2023 at 9:21am.

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. LPA requested and received current facility LIC500.

The facility has an infection control plan in place. 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. Water temperature is 110 degrees. Facility temperature is 73 degrees. The facility has a locked medication cabinet, and the facility has an updated Centrally Stored Medication and Destruction record for each resident in each resident file. 4 resident and 3 staff files have all required documents. The facility also has the required postings through out the facility. The facility is clean and sanitary. The exterior emergency exits are clear of debris.


Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited. Exit interview was held and a copy of report was given to facility administrator Mary Jane Apuya.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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