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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318217
Report Date: 06/12/2024
Date Signed: 06/12/2024 05:42:58 PM

Document Has Been Signed on 06/12/2024 05:42 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CORINA CARE HOME 2FACILITY NUMBER:
340318217
ADMINISTRATOR/
DIRECTOR:		DRAGNEA, DUMITRUFACILITY TYPE:
735
ADDRESS:8744 SUPERB CIRCLETELEPHONE:
(916) 685-7049
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Dan DinesTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/12/24 at 3:00pm and met with Dan Dines, Administrator and stated the purpose of the visit. This visit is to conduct a Required - 1 Year Inspection. LPA was allowed entry into the facility that is licensed and fire cleared for a capacity of 4 Non ambulatory residents. Administrator certificate expires 11/30/2024.

LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, common areas, bathroom(s), activities room(s) and storage areas. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 106.7*F which is within the required range of 105-120*F. The temperature inside the facility measured at 68*F which is within the required range of 68-85*F. The most recent emergency drill was conducted on 6/8/24.

The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) and pull alarm system. Facility has central heating and air. LPA observed the area where the staff and resident files are kept and readily available for review.

LPA observed 2 staff and 2 client files and conducted interviews during this visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CORINA CARE HOME 2
FACILITY NUMBER: 340318217
VISIT DATE: 06/12/2024
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Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees-Current
Criminal Record Clearances LIS536-Current
Administrative Organization LIC309-Current
Designation of Administrative Responsibility LIC308-Submit
Personnel Report LIC500-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-NA
Surety Bond LIC402-NA
Facility Floor Plan/Plot Plan LIC999-Current
LIC610D-Submit
Fire Clearance (consistent with terms and limitations of license)-NA
Qualifications of Administrator/Facility Manager-Submit
Articles of Incorporation/Organization, Constitution and bylaws-NA
Partnership Agreement-NA
Control of Property-NA
Emergency Disaster Plan LIC610D-NA
Plan of Operation (Restricted Health Care Plan)-NA
Admission Policies and Procedures-NA
Health Screening Report-Facility Personnel LIC503-NA
Bacteriological Analysis of Private Water Supply-NA
In-service Training Program-NA
Medication Procedures-NA
Transportation Procedures-NA
Job Description/Personnel Policies-NA
Exemptions/Waivers and Exceptions-NA
First aid/CPR certificates-Current
Liability Insurance-Submit
Infection Control Plan-Submit with any addendums

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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