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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005120
Report Date: 02/16/2023
Date Signed: 02/16/2023 10:03:27 AM


Document Has Been Signed on 02/16/2023 10:03 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: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: 4DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Corina Dragnea - AdministratorTIME COMPLETED:
10:05 AM
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Licensing Program Analysts (LPA's) Ruth Wallace and Kim Viarella conducted an unannounced visit Required 1 Annual Inspection Visit. LPA met with Administrator and explained purpose of visit. Administrator's Certification expires 10/29/2023. There are currently four (4) residents at this time and there is 1 resident on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2 day perishable and 7 day nonperishable.

Fire extinguishers were inspected on 6/24/2022. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Hot water temperature was measured at 110.5 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. First Aid kit is on site and complete.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed two (2) resident and three (3) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility.

LPA received the following updated documents on today's date:
LIC 308 and Administrator Certificate.

No deficiencies cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview held with Administrator and a copy of report given at the conclusion of the visit.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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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