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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002558
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:11:23 PM

Document Has Been Signed on 10/23/2024 02:11 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/
DIRECTOR:
MUPUNDU, ELLIASFACILITY TYPE:
735
ADDRESS:1785 TUSCANY DRIVETELEPHONE:
(530) 713-7594
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 4CENSUS: 4DATE:
10/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Ellias MupunduTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analysts Hiratsuka and Mikkelson, conducted this unannounced case management visit in response to Alta California Regional Center issuing a Facility Action Report (FAR) on September 18, 2024.

The Regional Center issued the FAR because they stated the Medication Administration Record (MAR) did not match the dosage a resident was supposed to be given. The medication in question is a powder that is mixed into a liquid at the pharmacy. During today's visit, LPAs reviewed the medication bottle and the prescription. LPAs observed what the Regional Center considered the dosage supposed to be given to the resident is actually the total amount of the medication in the bottle meaning the water mixed with the powder. The label of the bottle shows what the prescription strength is and the frequency given (amount of milliliters (ml) given to resident) to the resident. The strength written on the bottle is 40mg/ 5ml. That is the total amount of liquid plus powder that is mixed together in the bottle. The frequency given (dosage) to the resident is 2.5 ml.
What LPAs observed was the administrator wrote the strength of the prescription wrong on the MAR, which read 40mg/ ml. The administrator admitted he omitted the 5 from the MAR, but the frequency given to the resident is correct at 2.5ml. LPAs observed the label on the bottle for the prescription strength is 40mg/ 5ml with frequency given of 2.5ml twice a day to the resident.

Based on LPAs' observation there is no violation because the label on the bottle for frequency given matches the MAR and the administrator corrected the MAR to have the total amount in the bottle to 40mg/ 5ml.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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