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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004382
Report Date: 01/26/2023
Date Signed: 01/26/2023 12:08:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/26/2023 12:08 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'S ELDERLY CARE HOMEFACILITY NUMBER:
507004382
ADMINISTRATOR:SUCALA, CORINAFACILITY TYPE:
740
ADDRESS:5397 PORT ALICE WAYTELEPHONE:
(209) 543-3827
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 6CENSUS: 6DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Corina SucalaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual/random visit on this date. LPA met with Corina Sucala Administrator Certificate expires on 4/24/2023.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 119 degrees Fahrenheit in resident bathroom. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present.

LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 3 resident and 1 staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were observed during this visit.

Exit interview held and a report given with appeal rights at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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