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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001986
Report Date: 12/19/2024
Date Signed: 12/19/2024 11:48:02 AM

Document Has Been Signed on 12/19/2024 11:48 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SOL EDNAVE CARE HOMEFACILITY NUMBER:
347001986
ADMINISTRATOR/
DIRECTOR:		SOLEDAD EDNAVEFACILITY TYPE:
735
ADDRESS:8434 SUNRISE WOODS WAYTELEPHONE:
(916) 681-2546
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 5TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:06 AM
MET WITH:Lyn Manugo and Kimberly EspirituTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a case management visit on 12/19/24, at 10:00 AM. LPA Lee met with care staff Lyn Manugo and Corazon Ebilane and explained the purpose of the visit. Care staff Lyn called and informed Assistant Administrator, Kimberly Espiritu to informed that CCLD was present in the home. The census is 4.

The purpose of today's visit is to follow up on an incident report concerning an AWOL event that occurred on 12/15/24. It was determined that Client 1 (C1) successfully left the facility unattended at 6:30 AM. Facility staff contacted law enforcement to report a missing person. At 9:50 AM, the deputy informed the care home that C1 had been located. By 10:00 AM, C1 was escorted back to the facility by the deputy. It was revealed that C1 was found inside an unlocked moving truck, located just a few houses away from the care home. The truck's owner noticed C1 while preparing for work. Additionally, C1's LIC 602 Physician’s Report, dated 04/22/24, states that C1 is able to leave unassisted with the direction of 1:1 supervision. Staff reported that if C1 were to leave the facility unattended, C1 would not have the ability to return independently. According to C1’s Power of Attorney (POA), C1 is non-ambulatory and unable to leave the facility unassisted. Furthermore, C1 is in the process of transitioning to another care home that can provide a higher level of care, including 24/7 nighttime supervision.

Based on today’s case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is assessed on 12/19/24 due to lack of care and supervision and an immediate health and safety risk to C1. An exit interview was conducted with care staff. A copy of this LIC 809, LIC 809-D and appeal rights was provided to the facility at the end of the visit.

Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Pang LeeTELEPHONE: (916) 508-9726
DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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Document Has Been Signed on 12/19/2024 11:48 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: SOL EDNAVE CARE HOME
FACILITY NUMBER: 347001986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:

Deficient Practice Statement
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POC Due Date: 01/03/2025
Plan of Correction
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Administrator agrees to conduct care and supervision in-service training to all facility staff by 01/03/25. Administrator will email LPA Lee copies of training sign in sheet of, training materials used and a statement of acknowledgement of
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) 214-5136
Pang LeeTELEPHONE: (916) 508-9726

DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024

LIC809 (FAS) - (06/04)
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