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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005547
Report Date: 06/16/2022
Date Signed: 06/16/2022 04:27:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/16/2022 04:27 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 HOMEFACILITY NUMBER:
347005547
ADMINISTRATOR:DRAGNEA, CORINAFACILITY TYPE:
740
ADDRESS:8840 KELSEY DRIVETELEPHONE:
(916) 215-0365
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Corina Dragnea, AdministratorTIME COMPLETED:
08:39 AM
NARRATIVE
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Licensing Program Analyst (LPA) R. Campbell and Licensed Program Manager Liza King arrived to the facility at approximately 08:30 am to conduct an unannounced Annual Inspection visit to the facility on today's date of 06/16/2022. LPA was greeted by staff Dragos Axente and met with Administrator Corina Dragnea. LPA explained that the purpose of the visit was to conduct a required annual inspection. Administrator stated that currently, there are 5 clients that live in the home. Corina Dragnea administrator certificate #6004207740 expires 09/02/2023.

LPA evaluated the physical plant to ensure the health and safety of the residents in care. LPA inspected the facility with Administrator including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room, and backyard. LPA observed the facility to be free of odor, clean and in good repair. There are no bodies of water present in the facility at this time. LPA observed sufficient seven day non-perishable and two-day perishable food supplies. Fire extinguishers were in compliance.

Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed today. Appeal rights were provided.

Exit interview conducted. A copy of this report was left with Corina.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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Document Has Been Signed on 06/16/2022 04:27 PM - It Cannot Be Edited


Created By: Renee Campbell On 06/16/2022 at 12:06 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CORINA ELDERLY HOME
FACILITY NUMBER: 347005547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited
CCR
87468.1(a)(2)

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(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

3of3 Staff were observed going without a mask while working in the facility. Visitors were not required to sign in, were not screened for symptoms of Covid 19.
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Administrator will provide current information about covid infection control procedures, require all staff to wear a mask while working in the facility and facility willd require that all visitors be screened. Administrator will provide documentation of staff training on infection control.
Type A
06/17/2022
Section Cited
CCR
87202(a)(2)

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All faciilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2)Bedridden Person, Based on observation and interview with the administrator, residents , the facility does not have current clearance for bedridden persons.
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Administrator will submit an LIC 200 for a change in ambulatory status in one day via email to LPA.
Type B
07/16/2022
Section Cited
CCR87705(c)(5)

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Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Based on record review and interview, the licensee failed to obtain/maintain health screening documentation for 3 of 4 residents.
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Administrator will arrange health screenings and obtain updated 602 for all residents in 30 days . Licensee will obtain the updated 602 in 30 days and will provide proof via email to LPA R. Campbell
Type B
07/16/2022
Section Cited
CCR
87463(c)

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The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
Based on record review , 4 of 4 residents did not have a reappraisal completed in the past 12 months.
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Administrator will provide appraisals for all residents missing an updated reappraisal within 30 days and will provide proof via email to LPA.
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
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
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