<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700185
Report Date: 02/24/2022
Date Signed: 02/24/2022 03:56:23 PM

Document Has Been Signed on 02/24/2022 03:56 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:CUPINO HOMEFACILITY NUMBER:
342700185
ADMINISTRATOR:CUPINO, RAULFACILITY TYPE:
735
ADDRESS:8636 LILYPAD LANETELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
02/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Raul CupinoTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey-Canady conducted a case management inspection of Cupino Home. LPAs met with Licensee Raul Cupino to ensure the facility is in compliance with applicable statutes and regulations. Licensee called Assistant Administrator Monica Butay to the facility to continue with the visit. LPAs confirmed that zero staff and zero residents have displayed any signs or symptoms of COVID-19 in the last 10 days.

During the visit, the LPAs conducted interviews with staff, the licensee, and the Administrator. Based on interviews, staff receive pay checks bi-weekly, never receive a late pay check, have waived breaks, and are paid if work over time. There is not any live-in care staff. LPA reviewed staff files, resident files, and resident medication records. LPAs observed files to be up to date with necessary documents.

The LPA conducted a tour of the physical plant and observed the facility to be within compliance with Title 22 regulations. Common areas were clean and free of debris. Resident rooms has necessary furniture and furnishings. The facility had an adequate amount of food and an emergency supply in the pantry.

Based on interviews, file/medication reviews, and observation of the physical plant, it appears the facility is in compliance with applicable statues and regulations. Therefore, the facility appears to be in good standing.
An exit interview was held with Designated Assistant Administrator Monica Butay and a copy of the report was left for Licensee Raul Cupino.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1