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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002791
Report Date: 08/30/2023
Date Signed: 08/30/2023 11:39:11 AM

Document Has Been Signed on 08/30/2023 11:39 AM - 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 3FACILITY NUMBER:
515002791
ADMINISTRATOR:MALEKANO, MAYAFACILITY TYPE:
735
ADDRESS:2519 SOMERSET WAYTELEPHONE:
(530) 329-3480
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 4CENSUS: 4DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Melody MwakalombeTIME COMPLETED:
11:45 AM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Caregiver Melody Mwakalombe. There was one resident present during the visit.

This facility has a fire clearance for three ambulatory and one non-ambulatory residents. The facility has four private resident rooms; two full common bathrooms and the largest room has a full private bathroom; laundry room; two common areas; dining and kitchen. There is a door leading to the garage from the facility. There are locked cabinets for medications and records. LPA reviewed four resident and four staff files.

The following shall be updated and submitted to Community Care Licensing Division by September 15, 2023:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibility
-LIC 610 emergency disaster plan.

No deficiencies were observed.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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