392700366-7-18-2023-27-AS-CYAG-CTUN7N-20230718101300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700366
Report Date: 07/17/2023
Date Signed: 07/18/2023 10:13:04 AM

Document Has Been Signed on 07/18/2023 10:13 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, 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: 84	DATE:	07/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sheri Kimbro		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 07/17/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Sheri Kimbro, who was briefly interviewed at this time. Current census was 84 residents. It was learned that there were (9) residents under the care of home health at this time. A total of (3) residents under home health resided in the Memory Care Unit while (6) residents were under the care of home health in the Assisted Living portion at this time. There were a total of (7) residents under the care of hospice at this time. A total of (4) residents were under the care of hospice in Memory Care while there were (3) residents under hospice care in the Assisted Living side of this facility. Tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities at this time. Walk in pantry area, refrigeration unit, and freezer unit were toured. Brief tour of the food preparation line was conducted. Brief interview conducted with the supervising representative for the kitchen at this time. Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be present and maintained in compliance at this time. A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in compliance at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Medication carts, located outside of the medication room, were reviewed. Policies and procedures for

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, THE	FACILITY NUMBER: 392700366
	VISIT DATE: 07/17/2023

NARRATIVE

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dispensing, handling, and overall documentation of the resident medications were discussed with the facility medication technician at this time.
Fire extinguishers were observed to be placed throughout this facility and were annually inspected on 04/03/2023 by the local fire equipment company, Edison Fire Extinguisher, and in compliance at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Linen closet, located in facility hallway, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use.
Laundry areas, located along facility hallways, were observed to be made available to the residents at this time for those who were capable of doing so. Laundry detergents, bleach, and all other cleaning supplies were observed to be stored elsewhere where they were locked and made inaccessible to the residents at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, side gates, and emergency exits were reviewed.
Additional shed in the backyard area was reviewed and observed to be contain materials and items intended for upkeep and maintenance of this facility.

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

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC809 (FAS) - (06/04)

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