392700366-7-19-2024-27-AS-CYAG-D7BQHG-20240719121107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700366
Report Date: 07/17/2024
Date Signed: 07/19/2024 12:11:38 PM

Document Has Been Signed on 07/19/2024 12:11 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	COMMONS AT UNION RANCH, THE		FACILITY NUMBER:	392700366
ADMINISTRATOR:	SHERI KIMBRO		FACILITY TYPE:	740
ADDRESS:	2241 N UNION ROAD		TELEPHONE:	(209) 463-9100
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	135	CENSUS: 96	DATE:	07/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sheryl Bravo		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Annual visit made out to this facility on 07/17/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time. This facility was not vendorized at this time to accept and retain any regional center clients at this time. Current census was 96 residents. It was learned that there were (10) residents under the care of hospice at this time. This facility has an approved hospice waiver to be able to accept/retain up to (25) residents at any given time. It was learned that there were (21) residents diagnosed with dementia at this time. It was learned that there were (12) residents receiving services through home health agencies at this time. A tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. Additional food storage units were observed to be present and in use at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet and supplies, located in the facility dedicated medication room, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated staff person at this time. This medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen storage closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 392700366
	VISIT DATE: 07/17/2024

NARRATIVE

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inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 04/02/2024 by the local fire extinguisher company, Edison Fire Extinguisher Inc, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted.
A review of (8) facility resident records was conducted and noted on the following LIC 858 form.
A review of (8) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/19/2024 12:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 392700366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [8] facility personnel records was not properly cleared for TB by a licensed medical professional which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility personnel records will be reviewed to make sure that all of them are properly cleared, with documentation from a licensed medical professional, for TB at all times. A statement of correction, along with copies of all updated and completed TB clearances, will be completed and submitted into CCL by the due date of 07/18/2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/19/2024 12:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 392700366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [7] out of [8] facility resident files were incomplete missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all resident records will be reviewed to make sure that all of them are properly updated to include the required forms and documents at all times. A statement of correction, along with copies of all updated and completed forms, will be completed and submitted into CCL by the due date of 07/24/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/19/2024 12:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 392700366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(c)(5)

Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [8] facility resident records did not have an updated annual medical assessment to address care of persons diagnosed with dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all residents diagnosed with dementia will be reviewed to make sure that their annual medical assessments have been updated with complete records in their respective files. A statement of correction, along with copies of updated medical assessments addressing care needs for dementia, will be completed and submitted into CCL by the due date of 07/18/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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