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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003472
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:24:26 PM


Document Has Been Signed on 11/30/2023 02:24 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CORNELIA'S RCFEFACILITY NUMBER:
347003472
ADMINISTRATOR:CORNELIA CATAFACILITY TYPE:
740
ADDRESS:5422 NORTH AVENUETELEPHONE:
(916) 489-3299
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cornelia Cata, Administrator TIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Administrator, Cornelia Cata and explained purpose of inspection. Also present was Lupe Molina, assistant. Rodrica Madaline Cata arrived at approximately 11:45 am. LPA observed (4) residents in the common area and (2) residents in their resident rooms. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4).

LPA and the Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms, each with a half bathroom and (1) full bathroom with a large shower, kitchen, staff rooms and locked laundry area. LPA observed the facility to be clean, in good repair and odor-free, and the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable, including fresh produce, and 7+day non-perishable supply of food. Sharps are locked in the kitchen and medications are secured in a nearby cabinet. Toxins are locked in the laundry room. LPA observed sufficient linens/blankets/incontinent supplies, PPE, and a complete First Aid kit. The inside temperature was 69*F. Hot water temperature measured 116*F in the bathroom. Fire extinguisher last serviced 1/6/2023. Quarterly fire drills conducted -last drill Oct 2023. Fire doors (2) are in compliance with regulation. There is an unlocked gate outside and covered seating on the patio.

LPA reviewed (3) resident files and found them to be complete and contain current paperwork. Medications were reviewed for (2) residents and no discrepancies were noted. Medication documentation is current and accurate. (2) staff files were reviewed. Both staff have current First Aid/CPR on file. Administrator of record has current RCFE Administrator certificate valid through 3/14/25- #6025206740. Second staff will be renewing her Admin certificate by 12/21/23 (exp). LPA reviewed the Infection Control Plan (LIC9282) and found it complete. Emergency Disaster Plan was reviewed also. Discussed updated forms. LPA obtained updated copy of liability insurance. LIC308 and LIC500 due by 12/8/23. There are no deficiencies issued but there is a Technical Advisory Note being issued. Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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