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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003472
Report Date: 06/29/2023
Date Signed: 06/29/2023 12:19:46 PM

Document Has Been Signed on 06/29/2023 12:19 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
06/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Cornelia CataTIME COMPLETED:
12:30 PM
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On 6/29/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with licensee.

On 6/20/23, LPA Mknelly was present at the facility and advised licensee of some best practices for food and medication storage. LPA returned today to review the corrections put in place.
The home is clean, residents are receiving identified assistance and food and medications are properly stored.

As a result of today’s inspection, no deficiencies were noted.



Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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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