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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200575
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:56:04 PM


Document Has Been Signed on 09/23/2022 02:56 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: 89DATE:
09/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brittany Karlinski, AdministratorTIME COMPLETED:
02:30 PM
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On 09/23/22 at 2PM, while at the facility for another reason, Licensing Program Analyst (LPA) Daisy Panlilio discussed the self reported theft incidents (SOC 341s) which both occurred on 09/07/22 with resident (R1, Assisted Living) and resident (R2, Memory Care) .

R1's gold cross pendant and chain were reported lost on 09/07/22 to Resident Care Director (RCD) on 09/07/22. The next day R1's husband notified RCD that R1's gold cross pendant and chain were found taped outside the front door of her apartment. Another resident (R2) reported a missing costume jewelry in memory care on 09/07/22. An in-service staff retraining on safeguard of property and valuables was conducted by RCD and Memory Care Director (MCD) on 09/09/22.

No deficiencies cited during visit. Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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