<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002558
Report Date: 11/02/2022
Date Signed: 11/02/2022 12:32:03 PM

Document Has Been Signed on 11/02/2022 12:32 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
CHICO - RESIDENTIAL, 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:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Ellias MupunduTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed the staff wearing surgical masks.

The main entrance opens to a common area. There is a hallway to the right of the main entrance that leads to four private rooms, laundry room, locked closet that stores medications and records, and a door that leads to the garage. There is one full common bathroom and the largest room has a full private bathroom. Past the first common area towards the back is of the facility is the kitchen and a second common area. There is a sliding door leading to the backyard.

LPA reviewed staff and resident records.

LPA and Administrator discussed staff training and documentation.

A couple of other topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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 1