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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001881
Report Date: 01/24/2025
Date Signed: 01/29/2025 11:26:40 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/29/2025 11:26 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EDISON ESTATESFACILITY NUMBER:
347001881
ADMINISTRATOR/
DIRECTOR:		APUYA, MARY JANEFACILITY TYPE:
740
ADDRESS:3741 EDISON AVENUETELEPHONE:
(916) 484-7934
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Romeo ApuyaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Holly Williams arrived unannounced to conduct an annual inspection. LPA Williams met with the facility administrator on the phone Mary Jane Apuya (MJ) and explained the purpose of the visit. MJ said that Romeo Apuya Junior can sign for her.

LPA Williams reviewed three resident files (R1-R3) and staff files (S1).

LPA Williams toured the facility with Romeo Apuya Jr. and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 121.6 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. LPA Williams asked Apuya Jr. who is sleeping on the couch in the dining room because there was bedding and it looked slept in and Apuya Jr. stated his family member (FM). LPA Williams ask if the FM lived at the facility and Apuya Jr. said yes.

LPA Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Williams observed a locked cabinet for the storage of medication. LPA Williams observed locked cabinets for the storage of cleaning solutions and knives.

LPA Williams interviewed one staff member (S1) and one resident (R1).

This facility is being cited per 22 CCR Section 87303(e) and 87307(a). An exit interview was held with Apuya Jr. Appeal rights and a copy of this report were provided to Apuya Jr.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161
DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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Document Has Been Signed on 01/29/2025 11:26 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: EDISON ESTATES
FACILITY NUMBER: 347001881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based oobservation the licensee did not comply the water temperature was 121.6. degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/25/2025
Plan of Correction
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Licensee agrees to send picture of corrected water temperature. Licensee to send Title 22 87303(e)(2) written and include a statement of understanding by POC due date. holly.williams@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2025 11:26 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: EDISON ESTATES
FACILITY NUMBER: 347001881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply because the family member (FM) is sleeping on the couch in the dining room on the couch which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee agrees to remove the FM from sleeping in the dining room. Send a statement of understanding stating that the FM will not be living in the dining room including the Title 22 regulation87307(a)(2)(B) by POC due date. holly.williams@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025

LIC809 (FAS) - (06/04)
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