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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004382
Report Date: 02/26/2024
Date Signed: 02/27/2024 09:58:55 AM


Document Has Been Signed on 02/27/2024 09:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator Corina Sucala TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced annual/required visit. LPA met with Administrator Corina Sucala and explained the reason for the visit Census:5

LPA Lund & Administrator Corina Sucala 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 118 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 2 resident and 2 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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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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