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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002637
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:23:45 PM

Document Has Been Signed on 10/26/2023 03:23 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 HAVEN 2FACILITY NUMBER:
515002637
ADMINISTRATOR:MUPUNDU, ELLIASFACILITY TYPE:
735
ADDRESS:2007 FALLS DRTELEPHONE:
(530) 713-7594
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 4CENSUS: 4DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Antonio JacksonTIME COMPLETED:
03:33 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Caregiver Antonio Jackson

This main entrance opens to the first of two sitting areas. To the right of the main entrance is a very short hallway that leads to two private resident rooms. The larger of the two rooms has a full private bathroom and a sliding glass door leading to the backyard. To the left of the main entrance is a nook that is used as an office space. To the left of the first sitting area is a hallway leading to two private resident rooms, a full common bathroom, and a laundry room. To the left and rear of the main entrance is the kitchen and the second sitting area that has a door leading to the backyard. The backyard has a locked shed. There are locked cabinets for medications and confidential files.

four resident files were reviewed
three staff files were reviewed.

Several topics were discussed.

The following shall be updated and submitted to licensing within 30 days;
LIC 500- facility personnel or staff schedule
LIC 308- designation of administrative responsibility
LIC 610- emergency disaster plan

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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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