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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700366
Report Date: 05/05/2023
Date Signed: 06/09/2023 10:48:59 AM


Document Has Been Signed on 06/09/2023 10:48 AM - 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 UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:SHERI KIMBROFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 90DATE:
05/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karen SilvaTIME COMPLETED:
12:15 PM
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On 05/05/23, Licensing Program Analyst (LPA), Kimberly Viarella made an unannounced case management visit to this facility. LPA identified herself upon arrival and the purpose of the visit. LPA met with designated facility administrator, Karen Silva, and requested the following documents for a resident (R1) as part of an ongoing investigation.

Physician's Report
Admissions Agreements
Needs and Appraisal
Incident Reports
ID Emergency Contact
Charting Notes/Daily Notes

LPA conducted and exit interview with Karen Silva.
A copy of this report was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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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