<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003472
Report Date: 12/08/2021
Date Signed: 12/08/2021 03:17:45 PM

Document Has Been Signed on 12/08/2021 03:17 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CORNELIA'S RCFEFACILITY NUMBER:
347003472
ADMINISTRATOR:CORNELIA CATAFACILITY TYPE:
740
ADDRESS:5422 NORTH AVENUETELEPHONE:
(916) 489-3299
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 4DATE:
12/08/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Cornelia Cata, Administrator TIME COMPLETED:
03:20 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
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Administrator, Cornelia Cata and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Facility currently has (4) residents and (0) residents are on hospice. LPA observed (3) residents to be in the common area watching television and (1) resident to be resting in her room. Caregiver, Madaline Cata, was also present, and indicated she is waiting to receive her Administrator Certificate from the Department after completing her initial (80) hours.

LPA and Administrator toured the interior of the facility, including (6) private resident rooms with a half bath each, kitchen, laundry, caregiver room, office and common areas. LPA observed it to be clean and in good repair. LPA observed various Covid posters throughout. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 73* F. Fire extinguisher last serviced 1/14/2021. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed paper towels, soap, sanitizer and trash cans with lids in the bathrooms. Sharps, toxins and medications are secured appropriately. LPA and Administrator discussed vaccination status of residents and staff as well as visitation protocols per PIN 21-40. LPA observed signage/information posted at the front entrance that masks, documentation of vaccination status or negative Covid test within 72 hours are required upon entry.

LPA requested an updated copy of LIC308 (copy printed) and current liability insurance be provided to the Department by 12/15/2021. . Photo of updated Administrator certification taken during inspection.

There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1