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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318217
Report Date: 06/07/2022
Date Signed: 06/09/2022 03:20:12 PM

Document Has Been Signed on 06/09/2022 03:20 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CORINA CARE HOME 2FACILITY NUMBER:
340318217
ADMINISTRATOR:DRAGNEA, DUMITRUFACILITY TYPE:
735
ADDRESS:8744 SUPERB CIRCLETELEPHONE:
(916) 685-7049
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 3DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Dumitru Dragnea, AdministratorTIME COMPLETED:
12:45 PM
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On 05/26/2022, Licensing Program Analyst (LPA) R. Campbell and Licensing Program Manager L. King originally visited but due to technical difficulty, Licensing Program Analysts (LPA's) R. Campbell and R. Wallace returned for follow up visit based on observed deficiencies. LPA's met with Licensee and wife and explained the purpose of today’s inspection. LPA's were allowed entry into the facility that is licensed to serve a total capacity of 4 non-ambulatory clients. All staff were wearing masks and COVID protocol was completed upon arrival. Stations at front entry is accessible to residents and guests to avoid spread of COVID.

LPA's toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. There are no bodies of water observed. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPA's observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 109.2 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishable and 2-day perishables foods. LPA's observed client medications in individual labeled baskets.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on May 26, 2022 LPA's collected mitigation plan from Administrator. LPA's reviewed mitigation plan with Administrator and provided guidance. First aid kit was observed to be complete. Fire drill was last conducted on 04/22/22.

Continued on 809-C Page 2
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CORINA CARE HOME 2
FACILITY NUMBER: 340318217
VISIT DATE: 06/07/2022
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Continued from 809 - Page 2

-LPA observed posted facility sketch and office file facility sketch which requires updating.

Buildings and Grounds
-LPA requested an updated fire clearance be sent by June 14, 2022 via email to LPA R. Campbell.
-LPA observed a bedroom closet wall which had a hole was repaired.

LPA's observed old television, metal doors, debris, old wood in backyard, and basketball hoop in backyard area which still needs to be installed or moved from facility.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Deficiencies are being cited today in violation of California Code of Regulations.

Exit interview conducted with Administrator and a copies of reports/appeal rights given at the conclusion of the visit.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2022 03:37 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/09/2022 03:25 PM


Created By: Renee Campbell On 06/07/2022 at 12:09 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CORINA CARE HOME 2
FACILITY NUMBER: 340318217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above due to old television, metal doors, debris, old wood in backyard, and unused basketball hoop which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2022
Plan of Correction
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LIcensee agrees to submit pictures of all items removed from backyard to LPA Campbell via email by POC Date of 7/07/22. Old television, metal doors, debris, old wood in backyard, and move basketball hoop to concrete area to be completed by POC Date of July 7, 2022.
renee.campbeoll@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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