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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700366
Report Date: 07/20/2022
Date Signed: 08/02/2022 03:59:54 PM


Document Has Been Signed on 08/02/2022 03:59 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:DIANA BORZAFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 91DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sheri KimbroTIME COMPLETED:
12:30 PM
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Unannounced annual visit made out to the facility on 07/20/2022 by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua who were met by the facility designated Administrator Sheri Kimbro who was briefly interviewed.
Current census was 91 residents.
Tour of this facility was conducted.
Living areas, dining areas, and all other areas intended for resident were toured and observed to contain adequate furniture and furnishings to meet the needs of the residents at this time.
Kitchen area was toured. Food supply was reviewed for adequate 7-day nonperishable and 2-day perishable food quantities. Food storage units were reviewed.
A tour of the resident rooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents.
A tour of the resident restrooms was conducted. Grab bars and non skid mats 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.
Medication cabinet was reviewed. It was learned that narcotics and all other medications were housed in medication carts that were used to store and dispense medications to the residents at this time. This facility employed an electronic Medication Administration Record system at this time. A brief interview was conducted with facility staff responsible for handling, dispensing, and documentation of the medications at this time.
A tour of the facility memory care unit was conducted.
Fire extinguishers, located and placed throughout the facility, were observed to have been annually inspected on 04/06/2022 by the local fire extinguisher company noted as Edison and in compliance at this time.
A tour of the exterior grounds was conducted.
A review of the perimeter fence and side gates was conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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: 07/20/2022
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There were no deficiencies observed or cited during todays annual visit.

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

LIC 308

LIC 400

LIC 500

LIC 610

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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