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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002791
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:06:58 PM

Document Has Been Signed on 08/22/2024 01:06 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 HAVEN 3FACILITY NUMBER:
515002791
ADMINISTRATOR/
DIRECTOR:		MALEKANO, MAYAFACILITY TYPE:
735
ADDRESS:2519 SOMERSET WAYTELEPHONE:
(530) 329-3480
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 4CENSUS: 4DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Maya MalekanoTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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LPA Hiratsuka conducted this unannounced case management visit in response to a resident who left the facility without permission on August 15, 2024, and found the next day. The physician's report states the resident may leave the facility unassisted and so does another document. LPA obtained both documents during today's visit. The resident returned without any injuries or lasting effects. Safety suggestions and documentation for the resident were discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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