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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200575
Report Date: 12/29/2022
Date Signed: 12/29/2022 02:35:32 PM


Document Has Been Signed on 12/29/2022 02:35 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:BRITTANY KARLINSKIFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 90DATE:
12/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Diane Taylor, Interim Health DirectorTIME COMPLETED:
02:45 PM
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On 12/29/22 at 2:25PM, while at the facility for another reason, Licensing Program Analyst (LPA) Daisy Panlilio met with interim Health Director (IHD) to follow-up on a self reported theft incident that occurred on 12/21/22. LPA explained the purpose of the visit with IHD.

IHD stated an internal investigation is being conducted to address the theft wherein resident's son reported that approximately $6,300 was stolen from resident's credit card/debit card including $100 in cash. A police report was also filed.

IHD also shared that another theft incident occurred on 12/27/22 with another resident's debit/credit cards (2) amounting to approximately $400. Per IHD, an incident report was submitted to CCLD yesterday.

IHD stated facility is currently investigating both incidents and take necessary steps to resolve the issue.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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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