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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003472
Report Date: 04/26/2022
Date Signed: 04/26/2022 05:04:59 PM

Document Has Been Signed on 04/26/2022 05:04 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: 6DATE:
04/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Adrian Cata, caregiver and Cornelia Cata, Administrator TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met with Adrian Cata, caregiver, who contacted Administrator, Cornelia Cata. LPA 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: KN95 mask. Facility currently has (6) residents and (1) resident is on hospice.

LPA discussed balance on account. Administrator stated she believed she paid by sending a check in the mail. Administrator to research check number. LPA to follow up with more information on last payment received and provide PIN to allow for payment on line.

LPA toured the interior of the facility and observed residents to be napping and watching television. LPA observed the facility to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation.

There are no deficiencies being cited on this report.

Exit interview. Copy of report to be emailed to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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