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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700366
Report Date: 11/27/2023
Date Signed: 11/28/2023 09:55:07 AM


Document Has Been Signed on 11/28/2023 09:55 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 89DATE:
11/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Karen SilvaTIME COMPLETED:
04:00 PM
NARRATIVE
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Unannounced Plan of Correction visit made out to this facility on 11/27/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the Resident Services Director, Karen Silva, who was briefly interviewed at this time.
Current census was 89 residents.
The purpose of this visit was to verify the plan of corrections that were required to be completed and submitted into CCL for deficiencies that were cited and due by 11/23/2023.
The Plan of Correction letters were generated and a copy was left with the facility designated representative at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
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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