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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700369
Report Date: 08/07/2023
Date Signed: 08/07/2023 02:43:06 PM


Document Has Been Signed on 08/07/2023 02:43 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:COMMONS AT ELK GROVE, THEFACILITY NUMBER:
342700369
ADMINISTRATOR:MEGGIN CORTEZFACILITY TYPE:
740
ADDRESS:9564 SABRINA LANETELEPHONE:
(916) 683-6833
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:110CENSUS: 83DATE:
08/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Meggin CortezTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. The report described a physical altercation between two residents (R1-R2).

LPA Moleski interviewed Cortez and a staff member (S1). LPA Moleski reviewed R1's and R2's file.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Cortez.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023
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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