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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700366
Report Date: 09/25/2024
Date Signed: 09/27/2024 09:33:06 AM


Document Has Been Signed on 09/27/2024 09:33 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:SHERYL BRAVOFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 100DATE:
09/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marcy BorlandTIME COMPLETED:
12:00 PM
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Unannounced case management visit conducted on 09/25/2024 out to this facility by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative, Business Office Manager Marcy Borland, who was briefly interviewed at this time.
Current census was 98 residents.
The purpose of this case management visit was to follow up and inquire about recent incident reports in regards to facility residents and their related care.
An interview was conducted with the facility designated representative Marcy Borland in regards to these incident reports.
A phone call was also made to the facility designated Administrator Sheryl Bravo to inquire and discuss these incident reports as well.
It was learned that this facility self reported a medication error that took place in regards to a resident's care and supervision. This facility did take steps to address the concerns of the responsible parties involved, train and evaluate all facility personnel responsible for handling and dispensing medications, and put into place updated policies and procedures to prevent future infractions.

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

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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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