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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005546
Report Date: 06/22/2023
Date Signed: 06/22/2023 11:12:14 AM


Document Has Been Signed on 06/22/2023 11:12 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: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:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Corina Dragnea - Administrator TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Annual 1 Year Required Inspection visit. LPA met and explained purpose of visit to administrator. Administrator certificate (#6004207740) expires on 09/02/2023.
LPA and administrator 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. The temperature inside the facility was observed to be at 76*F which is within the required range of 68-85*F. The hot water temperature was measured at 111.8*F which is within the required range of 105-120*F.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on June 24, 2022. 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 two of six residents’ files and three staff files.

LPA received the following updated documents for CCL:
LIC 308 - Designation of Administrator, Liability Insurance, and Administrator Certificate.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited.
Exit interview conducted with administrator and copy of report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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