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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005546
Report Date: 06/11/2025
Date Signed: 06/11/2025 05:14:24 PM

Document Has Been Signed on 06/11/2025 05:14 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CORINA ELDERLY HOME 2FACILITY NUMBER:
347005546
ADMINISTRATOR/
DIRECTOR:		DRAGNEA, CORINAFACILITY TYPE:
740
ADDRESS:9411 SKYDOME STREETTELEPHONE:
(916) 215-0365
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
06/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Corina DragneaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 06/11/2025 unannounced annual inspection was made to this facility by Licensing Program Analyst (LPA) Sommer Hayes. The LPA identified themselves and the purpose of the visit and asked to speak to the Designated Facility Administrator (DFA). LPA was met by Corina Dragnea and a brief interview followed.

LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents. The current census is 6.

LPA Hayes toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed.



All notices that are required to be posted have been posted and are in a highly visible area.

LPA Hayes toured the facility with the Designated Facility Administrator (DFA), Corina Dragnea.
The kitchen was accessible to residents and clean and sanitary. The LPA observed 7 days of non-perishable and 2 days of perishable food supplies. There is enough clean plates, cups and bowls and cutlery to meet capacity.

Continued on 809-C
Stephen RichardsonTELEPHONE: (916) 263-4746
Sommer HayesTELEPHONE: (916) 217-0362
DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2025
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: CORINA ELDERLY HOME 2
FACILITY NUMBER: 347005546
VISIT DATE: 06/11/2025
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Opened packages in the refrigerator were dated appropriately. All pantry items were dated as well.

Water temperature measured 106.9 degrees F within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguisher inspected were charged on 05/28/25 by Fire Code Safety Equipment. A smoke detector in living room was tested and working. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secured. The medication administration record (MAR) was reviewed.



The garage is not accessible to residents and contained non-perishable food supplies and cleaning supplies locked in a cabinet and a refrigerator.

LPA observed the backyard of the facility to be clean and free of obstruction. There was a shaded area for residents to enjoy and a walking path. Fencing was in good repair. There were no bodies of water. A first aid kit was observed containing a first aid manual, tweezers, scissors and gauze.

The facility living room was clean and free of obstruction. The temperature reading was 77 degrees Fahrenheit per Title 22 regulations. The seating is efficient seating for the number of residents in this facility.


LPA observed 7 sharp objects accessible to residents found in the front yard and in an unlocked kitchen drawer.

Per California Code of Regulations, Title 22, 1 deficiency was observed during today’s visit. Exit interview was conducted. A copy of this report was provided to DFA, Corina Dragnea.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Sommer HayesTELEPHONE: (916) 217-0362
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/11/2025 05:14 PM - It Cannot Be Edited


Created By: Sommer Hayes On 06/11/2025 at 04:43 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CORINA ELDERLY HOME 2
FACILITY NUMBER: 347005546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of seven (7) sharps accesible to residents in care. One located in the front yard and 6 located in the kitchen. The licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2025
Plan of Correction
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Administrator, Corina Dragnea will email LPA Hayes at sommer.hayes@dss.ca.gov by June 18, 2025 with a statement that she read the above Title 22 regulation by signing a sgned statement of acknowledgement.
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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 263-4746
Sommer Hayes
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 217-0362
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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