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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005546
Report Date: 07/08/2021
Date Signed: 07/08/2021 11:44:35 AM

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:CORINA ELDERLY HOME 2FACILITY NUMBER:
347005546
ADMINISTRATOR:DRAGNEA, CORINAFACILITY TYPE:
740
ADDRESS:9411 SKYDOME STREETTELEPHONE:
(916) 215-0365
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: DATE:
07/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Corina DragneaTIME COMPLETED:
11:45 AM
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On 7/8/2021 at 7:30am, Licensing Program Analyst (LPA) Ashley Boothe spoke with Licensee Corina Dragnea regarding facility risk assessment questions. Licensee confirmed no staff or residents have experienced symptoms within the last 10 days. At 8:30am, LPA arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Staff one (S1), explained the purpose of today’s inspection. S1 contacted Licensee who came to the facility about 45 minutes later. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 non ambulatory residents and 1 Hospice resident. Today's census is 6 of which 5 are non ambulatory and 3 Hospice Residents. Two of two staff observed with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 9/2/2021.

LPA interacted with a random number of residents during this visit and observed residents eating breakfast. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, garage, restrooms, bedrooms, and common living areas to be clean in good repair. The temperature inside the facility was measured at 72*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 105*F which is not less than 105 *F and not more than 120*F. LPA observed the centrally stored medications to be locked inaccessible to residents. All medications observed properly stored and labeled. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CORINA ELDERLY HOME 2
FACILITY NUMBER: 347005546
VISIT DATE: 07/08/2021
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LPA observed fire extinguisher last inspected on 7/31/2020, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted. LPA observed 5 resident files and 3 hospice care plans. LPA provided technical violation to resubmit Hospice Waiver Increase Request to the Department by close of business today. LPA observed Mitigation Plan to be submitted to the Department within 48 hours.

Upon a file review the following items were discussed to be submitted to LPA by 7/30/2021:
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Administrator Certificate
Emergency Disaster Plan LIC610E
Liability Insurance
Health Screening Report- Facility Personnel LIC503
First Aid/ CPR certificates

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed and cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC809 (FAS) - (06/04)
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