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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200575
Report Date: 02/17/2023
Date Signed: 02/17/2023 12:25:18 PM


Document Has Been Signed on 02/17/2023 12:25 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: 83DATE:
02/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Brittany Karlinski, Executive DirectorTIME COMPLETED:
12:30 PM
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On 02/17/23 at 12PM, while at the facility for another reason, LPA D Panlilio conducted an unannounced case management visit and met with executive director (ED). LPA explained the purpose of the visit with ED.

ED confirmed with LPA that staff (S1) was employed 5/12/2016 and was terminated 9/06/2017. Review of facility's current Personnel records (LIC 500) show S1 is no longer employed at the facility. Guardian Portal show S1 was disassociated from the facility on 06/19/2020.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to ED.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
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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