392700366-7-19-2021-27-AS-CYAG-C53VJG-20210719162842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700366
Report Date: 07/07/2021
Date Signed: 07/19/2021 04:28:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	COMMONS AT UNION RANCH, THE		FACILITY NUMBER:	392700366
ADMINISTRATOR:	MAUREEN BRADLEY		FACILITY TYPE:	740
ADDRESS:	2241 N UNION ROAD		TELEPHONE:	(209) 463-9100
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	135	CENSUS: 95	DATE:	07/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Tracy Freudendahl		TIME COMPLETED:	12:30 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 by LPAs Charlie Yang and Tirzah Hubbard on 07/07/2021 who were met by the Interim Executive Director Tracy Freudendahl. Brief interview was conducted with the Interim Executive Director. Current census was 95 residents. It was learned that this facility does have (9) residents under hospice care at this time. This facility is licensed to accept and retain up to (15) residents under hospice at any given time. Tour of this facility was conducted. Common areas were toured. Dining room, living areas, and all other areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair at this time. A sample of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A sample of the resident restrooms was conducted. Grab bars and non skid mats/surfaces were observed to be present and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Laundry areas were toured. Detergents, bleach, and cleaning agents were observed to locked and made inaccessible to the residents at this time. Linen closets were supplied with the necessary linens, blankets, and sheets sufficient to meet the needs of the residents. Memory care unit, Connections For Living, was toured. A sample of the resident bedrooms and restrooms were toured. A tour of the enclosed courtyard was conducted. Medication rooms were toured. Policies and procedures related to accepting, dispensing and documentation of the resident medications were discussed with facility personnel at this time. Kitchen area was toured. Food storage units were toured. A brief interview was conducted with the Director of Food Services. A review of the facility 2-day perishable and 7-day non perishable food quantities was conducted.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COMMONS AT UNION RANCH, THE	FACILITY NUMBER: 392700366
	VISIT DATE: 07/07/2021

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First aid kit was observed to be present and contained all of the necessary components at this time.
A tour of the exterior grounds was conducted. A review of the perimeter fence, side gates, and exterior exits was conducted.
Fire extinguishers, located throughout the facility, were observed to have been annually inspected on 04/13/2021 by the local fire extinguisher company Padilla's Fire Protection.
This facility was requested to go ahead and update the following forms at this time and to submit them 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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC809 (FAS) - (06/04)

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