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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318217
Report Date: 06/01/2023
Date Signed: 06/01/2023 05:05:45 PM

Document Has Been Signed on 06/01/2023 05:05 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:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dumitru DragneaTIME COMPLETED:
05:30 PM
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On 6/1/23 Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen arrived at the facility unannounced to conduct a required one year annual visit. LPAs Fain and Jensen met with Administrator Dumitru Dragnea and Luminita Dragnea explained the purpose of today's visit.

The facility is a single story building with a central entry point with sign in policy. Signage including but not limited to facility sketch, employee rights and resident rights were observed to be posted in prominent areas and visible to staff and residents.

LPAs Fain and Jensen toured the facility including but not limited to common areas, dining area, kitchen, pantry, administrative offices, 3 resident rooms and grounds. During the course of the visit LPAs engaged with 3 of 3 residents in care.

The kitchen was observed to be clean and sanitary. A seven day supply of non-perishable food and 2 day supply perishable food was observed. The refrigerator was maintained at 36 degrees and the freezer was 0 degrees which is in compliance with regulations.

The fire alarm and carbon monoxide detector were checked and determined to be in good working order. The fire extinguisher was last serviced on May 12, 2023 and is in compliance. Adequate lighting was observed throughout the facility including night lights in the hallways and motion detection lights outside. The facility temperature was set at 73 degrees which is within the required range of 68-85 degrees.

Continued on LIC 809C...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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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: 06/01/2023
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Continued from LIC 809....
The facility maintains medication in a locked storage cabinet that is inaccessible to residents. Toxins, disinfectants and sharp objects were observed to be stored in locked areas and are inaccessible to residents.

While touring the grounds, LPA's Jensen and Fain observed 2 barbecues, some treadmills and shaded seating for residents in the back yard. The window screens were in good repair. LPAs observed debris in the backyard including but not limited to a damaged basketball hoop, and overturned saw horses partially covered by a tarp. In addition a pool of standing water caused by a broken sprinkler pipe was observed by the tarp.

3 of 3 client files were reviewed and determined to be in compliance. 1 staff file was reviewed and determined to be in compliance.

The Inspection tool was used during the course of this inspection.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D during this visit. Civil Penalties are being assessed for repeat violations. The Licensee was provided a copy of their appeal rights. An exit interview was held and a copy of report and appeal rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/01/2023 05:05 PM - It Cannot Be Edited


Created By: Maja Jensen On 06/01/2023 at 04:05 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
, 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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
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 of debris including overturned saw horses and a tarp back yard and a broken water pipe causing standing water the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2023
Plan of Correction
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The Licensee agrees to fix the water leak and remove all debris from the backyard by the Plan of Correction due date. The Licensee agrees to email jennifer.fain@dss.ca.gov photos showing proof of correction.
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:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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