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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005120
Report Date: 09/22/2026
Date Signed: 09/22/2026 10:33:06 AM

Document Has Been Signed on 09/22/2026 10:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:D & C ELDERLY HOMEFACILITY NUMBER:
347005120
ADMINISTRATOR/
DIRECTOR:		CORINA DRAGNEAFACILITY TYPE:
740
ADDRESS:9474 Ranch Park WAYTELEPHONE:
CITY:Elk GroveSTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
09/22/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator Corina DragneaTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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On 09/22/2026 at approximately 9:40 AM, Licensing Program Analyst (LPA) Jamaly conducted an unannounced case management visit at the facility to follow up on the handling of resident cash resources identified during the investigation of complaint with CCN#27-AS-20260914085037. LPA met with the Administrator (AD) and explained the purpose of the visit.

During the complaint investigation, LPA obtained information indicating that the facility had accepted and maintained cash belonging to Resident 1 (R1), despite the facility's stated position that it did not handle resident cash resources.
During an interview conducted on 07/20/2026, and 9/22/2026, AD stated that the facility does not handle resident money. However, AD acknowledged that, upon R1's admission to the facility and at R1's request, the facility accepted $300 in cash belonging to R1 for safekeeping. AD stated that facility staff maintained a tracking sheet to document R1's expenditures and retained receipts for purchases made on behalf of R1. AD further stated that, at R1's request, the facility also maintained R1's identification documents.

On 07/15/2026, LPA reviewed R1's records and observed documentation supporting that the facility had accepted and maintained R1's cash resources. LPA observed LIC 405, Record of Client's/Resident's Safeguarded Cash Resources, containing a handwritten statement signed by AD and R1 which stated, "The facility will not handle the resident's money." LPA also observed documentation of R1's expenditures and receipts for purchases made on R1's behalf. In addition, LPA observed that the facility maintained a cash balance of $252.70 belonging to R1 in the facility.
LPA Jamaly reviewed the facility's LIC 400, Affidavit Regarding Client/Resident Cash Resources. The LIC 400 states that the facility will not handle any cash resources of persons within the facility.

Stephen Richardson
Reza Jamaly
DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: D & C ELDERLY HOME
FACILITY NUMBER: 347005120
VISIT DATE: 09/22/2026
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LPA reviewed the facility's Plan of Operation and R1's Admission Agreement, handling cash resources was not mentioned in those documents.

During the interview conducted on 09/15/2026, AD confirmed that the facility did not have a surety bond because the facility was not handling resident cash resources. LPA reviewed the facility records and did not observe LIC 402, Surety Bond, on file for the protection of resident cash resources.

Based on interviews, record review, and observation, the licensee accepted and safeguarded R1's cash resources without maintaining the required surety bond and without notifying the licensing agency and filing the required bond documentation.

Per California Code of Regulations (CCR) – deficiency was cited during today's visit. An exit interview was conducted with Corina Dragnea and a copy of this report with appeal right were provided to the facility..

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/22/2026 10:33 AM - It Cannot Be Edited


Created By: Reza Jamaly On 09/22/2026 at 10:07 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: D & C ELDERLY HOME
FACILITY NUMBER: 347005120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87216(a)

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87216 Bonding
(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.
This requirement was not met as evidenced by:
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The licensee/administrator will review the applicable regulations regarding the handling of residents’ personal funds. The licensee/administrator will submit a written statement confirming that the applicable regulations have been reviewed and that the facility will not handle residents’ funds unless the required surety bond is obtained.
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Based on interview and record review, the facility handled $300 of R1’s personal funds without a surety bond, which was inconsistent with the facility’s Plan of Operation which poses a potential risk to the health and safety of residents in 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2026


LIC809 (FAS) - (06/04)
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