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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002791
Report Date: 06/26/2024
Date Signed: 06/26/2024 03:16:36 PM

Document Has Been Signed on 06/26/2024 03:16 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:
06/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Maureen HamangabaTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Kerry Hiratsuka conducted this visit in response to Alta California Regional Center's Title 17 inspection done on May 22, 2024.

On May 22, 2024, Alta California Regional Center inspected the medication administration records (MARS), and found that one caregiver did not initial the date and time the medication was given to the residents. As a result, Alta California Regional Center issued a Facility Action Report (FAR) because the staff did not initial the date and time the medications were given to the residents. Alta California Regional Center representatives did not interview the residents to find out if the residents received their medications. Administrator Maya Malekano, informed LPA during a phone call the medications were given but not initialed and the staff underwent training for record keeping.

Today, LPA is issuing a citation because of the record keeping. Licensee/Administrator already submitted a written plan of correction stating the staff were given refresher training on record keeping for medication.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights were provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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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Document Has Been Signed on 06/26/2024 03:16 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 06/26/2024 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EDENIC HAVEN 3
FACILITY NUMBER: 515002791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
80022(a)

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Plan of Operation. Each licensee shall have and maintain on file a current, written, definitive plan of operation.
This requirement was not met as evidenced by:
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cleared. Licensee submitted a written plan of correction shortly after receiving the facility action report from Alta California Regional Center stating the staff have been given refresher training for medication administration record keeping.
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Based on Alta California Regional Center's Facility Action Report review, Licensee did ensure staff initialed the medication administration records for one day which poses a potential health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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