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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700368
Report Date: 06/14/2023
Date Signed: 06/14/2023 01:27:07 PM


Document Has Been Signed on 06/14/2023 01:27 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: 91DATE:
06/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Marie ArbiosTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit stemming from a complaint (27-AS-20230215120903). LPA was greeted by Executive Director and explained the reason for the visit.

During the course of the investigation of the above noted complaint it was discovered that reports of the thefts were reported to the ombudsmen's office and was verbally reported to LPA Lewis and Johnson but was not submitted in writing to the department.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, Deficiencies are being cited during this meeting. See 9099D page.

Exit interview conducted. copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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 06/14/2023 01:27 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: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2023
Section Cited
CCR
87211(a)(1)(d)

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D)Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission;
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Licensee/Administrator shall submit a Statement Of Understanding regarding the reporting requirements outlined in regulations by POC date via email
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This regulation was not met as evidence by: The licensee did not ensure that the facility provided a written report to licensing for the mutaple thefts at the facility. This poses a potential risk to residents in care.
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Statement shall include the requirements as outlined in the regulation identified in this citation.

POC already completed. Sent to LPA via email.

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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: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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