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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700185
Report Date: 01/07/2022
Date Signed: 01/07/2022 02:14:03 PM

Document Has Been Signed on 01/07/2022 02:14 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:
01/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Monica ButayTIME COMPLETED:
02:30 PM
NARRATIVE
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On 1-7-22 at 2:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to a complaint follow up. Complaint #27-AS-20211210155939. LPA met with Monica Butay, Assistant Administrator and explained the purpose of the visit. Administrator was notified and gave permission for Assistant Administrator to accommodate LPA and sign in his absence. During complaint visit on 1-7-22, LPA reviewed resident1 (R1) chart record and determined that physician's report was completed on 12-28-21. Further review of chart record revealed that resident was admitted 10/22/21. Based on today's visit, deficiencies are cited under Title 22, Division 6.

An exit interview was conducted with Monica Butay and a copy of this report was left with Monica. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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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Document Has Been Signed on 01/07/2022 02:14 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/07/2022 at 01:39 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: CUPINO HOME
FACILITY NUMBER: 342700185

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2022
Section Cited
CCR
80069(b)(e)

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Client medical assessment. (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (e) The licensing agency shall have the authority to require the licensee to obtain a current written medical assessment...to verifiy the appropriateness of a client's placement.
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Licensee provided a copy of completed physican report to LPA during visit.

Licensee will develop a plan to ensure physician reports for all clients present and future are completed timely. Plan to be submitted to LPA by POC due date.
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This requirement is not met as evidenced by: Based on record review and interview, Licensee did not ensure timely completion of a physician's report for R1. R1 was admitted 10-22-21 and Physician report was completed 12-28-21. This poses a potential health and safety risk to resident is care.
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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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2022


LIC809 (FAS) - (06/04)
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