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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200575
Report Date: 02/10/2021
Date Signed: 02/10/2021 04:26:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:ANDREWS, BRITANNYFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 84DATE:
02/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Brittany Andrews, AdministratorTIME COMPLETED:
04:20 PM
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On 02/10/21 at 3:40PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check via tele-visit as a result of the department receiving a priority 1 complaint during the COVID 19 shelter in place order. Administrator was not physically available to sign this report due to COVID-19 shelter in place order.

During health and safety check, LPA observed a total of 9 residents at facility. LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
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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