347005547-7-20-2023-27-AS-JFAN-CTX2ET-20230720172029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005547
Report Date: 07/20/2023
Date Signed: 07/20/2023 05:20:44 PM

Document Has Been Signed on 07/20/2023 05:20 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 AC/SC, 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: 5	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Corina Dragnea		TIME COMPLETED:	05:30 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 July 20, 2023 at approximately 9:00am, Licensing Program Analyst (LPA) Jennifer Fain and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Corina Dragnea and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an RCFE. Facility has 5 bedrooms and 5 bathrooms for resident use. Facility has a dining area off the kitchen and a sun room off the living room. Facility currently provides care for 0 ambulatory residents, 5 non ambulatory residents, and no hospice reside (waiver approved for 4). The facility has a central entry point and has sign in procedures at the front door area. Water temperature reads 109.4F* which is within the regulated temperature range of 105F to 120F in the bathroom and room temperature reads 75*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was serviced June 22, 2023 and is in compliance. Facility has an emergency food supply. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. During this inspection 4 of 5 resident files and 7 of 8 staffing files were reviewed for regulatory compliance. 2 of 8 staff files were identified as individuals providing medication assistance were missing annual medication training. All staff noted on LIC 500 contained criminal background clearances. 2 of the 7 staff files did not have the required direct support staff training. LPA completed 1 resident interview and 2 staff interviews.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CORINA ELDERLY HOME	FACILITY NUMBER: 347005547
	VISIT DATE: 07/20/2023

NARRATIVE

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Resident files reviewed contained all required contents including admission agreements, medical assessments, and updated appraisal forms as required. LPA observed 3 of 5 residents had physician's orders for bedrails. Centrally stored and prn logs were reviewed. TA was provided for ensuring that centrally stored logs contain the date a medication is opened. Additional TA was provided regarding communicating to a physician if a resident is provided a prn medication on a regular basis. TA was provided for documenting specifics on a prn medication log pertaining to pain location.

Facility does not contain any bodies of water. LPA observed cameras (2) in the main living area, Admin reported that the cameras were new and had an audio and video component. A review of the Admissions Agreement does not address the video cameras. Conversation with the Admin occured re: the need to disable the audio component of the cameras and the additional requirements to meet the residents personal rights to privacy. In addition, the LPA observed See Something/Say Something and complaint information posted. Facility has appropriate internet access available for resident use. Facility keeps a log of quarterly fire drills. LPA requested an updated copy of LIC 500, LIC 610E and copy of liability insurance be emailed to Jennifer Fain at jennifer.fain@dss.ca.gov by 7/27/23.

Per California Code of Regulations, Title 22, Deficiencies were cited. Exit interview was held and a report was given to Administrator Corina Dragnea

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2023 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CORINA ELDERLY HOME	FACILITY NUMBER: 347005547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(b)

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of 2/2 staff files that were identified by the Administrator as providing residents assistance with medication, annual medication training was not completed, thus the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	The licensee agrees to have staff whom provide medication assistance complete either the initial or annual training by the POC due dute. Proof of training will be submitted via email to Jennifer.Fain@dss.ca.gov

Type B

Section Cited

HSC

1569.625(b)

(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of 2 of 7 staff files, the licensee did not comply with the section cited above in which those 2 staff members did not have the required onboarding training requirement met of 40hours which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	The licensee will have the 2 staff complete the initial training and submit proof to the LPA Jennifer.Fain@dss.ca.gov by the POC due date.

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: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/20/2023 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CORINA ELDERLY HOME	FACILITY NUMBER: 347005547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(1)

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with the Administrator the facility has 2 camaras in the living room with an audio (not permitted) and video component, the Plan of Operation and Admissions Agreement were not updated to include this information. Therefore, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to remove the audio and video camaras from the premesis by the POC date and send pictures to the LPA Jennifer.Fain@dss.ca.gov

Type B

Section Cited

CCR

87705

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation a large serated knife was located in an unlocked drawer in the kitchen. In addition, 2 resident 602s documented that they were not allowed access to personal care supplies. During the facility tour personal care items were observed in the public bathroom, entry area, and bedrooms. Thus, the licensee did not comply with the section cited above. Since clients do not wander but can ambulate throughout the facility, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2023
	Plan of Correction
1 2 3 4	The licensee locked the knife during the visit. The licensee agrees to tour the home and remove all personal care items by the POC date. Staff training on the section cited will be provided to staff, a copy of the training will be provided to Jennifer.Fain@dss.ca.gov by the POC date.

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: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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