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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005546
Report Date: 06/20/2022
Date Signed: 06/20/2022 03:22:42 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/20/2022 03:22 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: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: 6DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Corina Dragnea, AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) R. Campbell and Licensed Program Manager Liza King conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator, Corina Dragnea. The administrator currently holds a certificate (#6004207740) that expires on 09/02/2023.
LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 6 bedrooms are occupied by the residents and 1 staff member occupies 1 room outside the main facility in a shed. . All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Water temperatures was initially measured at 80 degrees Fahrenheit but staff raised temperatures to 108.4 degree Fahrenheit.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on July, 14, 2021. Emergency Disaster Plan was last posted on 11/17/2020. First aid kit was observed to be complete.

LPA reviewed staff record files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. All staff have current first aid training. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. LPA reviewed 3 of 6 residents’ files and 4 of 4 staff files.

Administrator was given Technical Assistance due to missing structures from facility sketch and required saving of personnel documents.
Exit interview conducted. Copy of report provided. No deficiencies were cited during this inspection.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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