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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 10/27/2022
Date Signed: 11/07/2022 03:07:50 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221019141341
FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:DIANA BORZAFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sheri KimbroTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared staff is providing care and supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Unannounced complaint visit made out to this facility on 10/26/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Sheri Kimbro, who was briefly interviewed. Current census was 87 residents.
The purpose of this visit was to deliver the findings of this complaint investigation to this facility and it's designated Administrator.
Based on a review of documents and forms, it was learned that S1 has been employed at this facility since January 2022. A statement submitted by designated personnel representing the corporation for this facility revealed the appointment for S1 as the facility designated Administrator, Executive Director, and contained all of the necessary forms to support this action. A transfer request for the fingerprints and clearance for S1 were included in these documents.
This agency has investigated the complaint allegation(s). This agency has found that the complaint was UNFOUNDED, meaning that the allegation(s) were false, could not have happened and/or was without a reasonable basis. This agency has therefore dismissed the complaint.
There were no deficiencies observed or cited during today’s complaint visit. Exit Interview
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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