<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700368
Report Date: 05/17/2023
Date Signed: 05/18/2023 02:45:39 PM


Document Has Been Signed on 05/18/2023 02:45 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:COMMONS ON THORNTON, THEFACILITY NUMBER:
392700368
ADMINISTRATOR:ARBIOS, MARIEFACILITY TYPE:
740
ADDRESS:10711 THORNTON RDTELEPHONE:
(209) 476-1500
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:110CENSUS: 64DATE:
05/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:ARBIOS, MARIETIME COMPLETED:
01:00 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
Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit for an indent that occurred on 05/08/2023. LPA was greeted by Executive Director and explained the reason for the visit.

LPA reviewed R1'S file and took copies of the Physician's Report (602), hospital discharge orders email to R1's Physician, fax to the Physician and the needs and service plan.

R1 bought the medication on a shopping trip with facility staff (S1). the medication (Advil) bottle had a total of forty (40) pills when staff found R1 there was 28 of 40 pills left in the bottle R1 was holding 4 pills in their hand. The 4 pills are included in the 28. R1 told facility staff that they took 6 pills two (2) days later. Staff can't conform when pills were taken. Per R1's

LPA interviewed Executive Director about the incident. It was conformed during interview that the medication was bought on a shopping trip with facility staff.

Per California Code of Regulations, Title 22 deficiencies were observed or cited during today's case management inspection. See 809D page.

An exit interview was conducted and a copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/18/2023 02:45 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: COMMONS ON THORNTON, THE
FACILITY NUMBER: 392700368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2023
Section Cited
CCR
87464(f)(1)(c)

1
2
3
4
5
6
7
Basic Services (c) "Care and supervision" means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes ...personal care.
1
2
3
4
5
6
7
Licensee to schedule and conduct an in-service training on basic services, and care and supervision. Copy of training materials and list of attendees due to CCL. Training to be scheduled by 0518/2023.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: based on interview with Executive Director facility staff took R1 on a shopping trip in which they witnessed them buy the medication. This poses an immediate health and safety risk to resident.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2