347005547-7-8-2021-27-AS-ABOE-C4QRRT-20210708131540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005547
Report Date: 07/08/2021
Date Signed: 07/08/2021 01:15:51 PM

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		FACILITY NUMBER:	347005547
ADMINISTRATOR:	DRAGNEA, CORINA		FACILITY TYPE:	740
ADDRESS:	8840 KELSEY DRIVE		TELEPHONE:	(916) 215-0365
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 4	DATE:	07/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Corina Dragnea		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/8/2021 at :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 11:45am, LPA arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Licensee and was allowed entry into the facility that is licensed to serve a total capacity of 6 non ambulatory residents and 3 Hospice residents. Today's census is 4 of which 2 are non ambulatory and 0 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 lunch and returned from appointment. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, restrooms, bedrooms, and common living areas to be clean in good repair. The temperature inside the facility was measured at 75F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 111F 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 not 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 missing antiseptic solution. LPA observed oxygen tank not in use by Resident one (R1) stored in the garage, Licensee stated they did not know it was there and was missed when R1's other belongings were picked up after R1 passed away. Licensee contacted Hospice services to coordinate pick up from the facility during today's visit. LPA observed other items stored in the garage and Licensee stated they would clean it out. Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (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)

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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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CORINA ELDERLY HOME	FACILITY NUMBER: 347005547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(I)

Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements (I) Equipment shall be removed from the facility when no longer in use by the resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based observation and interview, the licensee did not comply with the section cited above in that one oxygen tank not in use by R1 was stored in the garage which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2021
	Plan of Correction
1 2 3 4	The licensee agrees to submit proof of Hospice Agency pick up by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CORINA ELDERLY HOME	FACILITY NUMBER: 347005547
	VISIT DATE: 07/08/2021

NARRATIVE

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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 3 resident files.

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. A signature on these forms acknowledges receipt of these documents. Appeal rights and a copy of this report provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (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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