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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002558
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:06:43 PM

Document Has Been Signed on 11/15/2023 04:06 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Ellias MupunduTIME COMPLETED:
04:10 PM
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Licensing Program Analysts (LPA) Hiratsuka and Yang, conducted this unannounced annual visit.

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 Yang reviewed medication records and staff records
LPA Hiratsuka reviewed two resident records.

A couple of other topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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