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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005120
Report Date: 02/22/2022
Date Signed: 02/22/2022 05:16:27 PM

Document Has Been Signed on 02/22/2022 05:16 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:D & C ELDERLY HOMEFACILITY NUMBER:
347005120
ADMINISTRATOR:CORINA DRAGNEAFACILITY TYPE:
740
ADDRESS:9474 RANCH PARK WAYTELEPHONE:
(916) 686-8312
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 3DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Corina DragneaTIME COMPLETED:
05:26 PM
NARRATIVE
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On 2-22-22 at 2:32pm, LPA Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Corina and explained the purpose of the visit. LPA conducted COVID-19 questioniere prior to entry and inspection. LPA donned PPE during visit as a precaution.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 3. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 107.2*F in the bathroom and room temperature reads 76*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 7-14-21. Facility has an emergency food and water kit. Four staff member charts were reviewed. First aid certifications reviewed. Staff4 (S4) first aid certification was observed to be expired. All COVID-19 vaccination current. One staff has an exemption in place for COVID-19 vaccination. All fingerprint clearances in place.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held with Corina Dragnea and a copy of this report was given to Corina. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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 02/22/2022 05:16 PM - It Cannot Be Edited


Created By: Michael Bilger On 02/22/2022 at 04:55 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: D & C ELDERLY HOME
FACILITY NUMBER: 347005120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff charts reviewed. S4's first aid certification is expired as of 12-29-2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2022
Plan of Correction
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Licensee will ensure first aid certification is in place for S4 prior to S4's return to normal working schedule. Licensee to submit proof of current first aid certification to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022


LIC809 (FAS) - (06/04)
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