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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700185
Report Date: 08/04/2023
Date Signed: 08/04/2023 09:24:51 AM

Document Has Been Signed on 08/04/2023 09:24 AM - 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:
08/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Monica ButayTIME COMPLETED:
09:30 AM
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 arrived unannounced to conduct a case management inspection of Cupino Home. LPA met with facility staff Adrian to ensure the facility is in compliance with applicable statutes and regulations. Facility staff called Assistant Administrator Monica Butay to the facility to continue with the visit.

During the visit, the LPA conducted interviews with staff. Based on interviews, staff receive pay checks bi-weekly, never receive a late pay check, always get breaks, and are paid if work over time. There is not any live-in care staff. LPA reviewed staff files.

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. Bathrooms were fully stocked with paper towels, soap, toilet paper, and a trash can. The facility had an adequate amount of food and an emergency supply in the pantry and in the garage. Residents were observed in their room, watching music videos, and dancing with staff. Staff were observed doing laundry, doing dishes after breakfast service, and cleaning resident rooms.

Based on interviews, file review, 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: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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