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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002558
Report Date: 11/23/2021
Date Signed: 11/24/2021 12:30:51 PM

Document Has Been Signed on 11/24/2021 12:30 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:EDENIC HAVENFACILITY NUMBER:
515002558
ADMINISTRATOR:MUPUNDU, ELLIASFACILITY TYPE:
735
ADDRESS:1785 TUSCANY DRIVETELEPHONE:
(530) 713-7594
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 4CENSUS: 4DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Ellias MupunduTIME COMPLETED:
02:00 PM
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11/23/2021 12:00 PM Licensing Program Analyst (LPA) Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Bbwaani Haamankuli Care Giver (CG) and spoke to Administrator (AD) MUPUNDU, ELLIAS over the phone. LPA explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted AD and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. Additionally, LPA Keane was screened by CG.

LPA Keane and CG toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) bathrooms four (4) bedrooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Keane and the CG completed the infection control domain per AD direction, and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was given to CG.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Dawn Keane
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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