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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700368
Report Date: 03/15/2024
Date Signed: 03/15/2024 12:49:41 PM


Document Has Been Signed on 03/15/2024 12:49 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 95DATE:
03/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ARBIOS, MARIETIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident reports received dated 1/18/2024 for incident that happened in late December and early January. LPA explained purpose of visit to the administrator.

The incident reports were multiple incidents of 911 calls for residents. LPA reviewed incidents reports and facilities training on reporting requirements, the facility had provided follow up training for staff regarding reporting requirements to ensure incidents are reported on time and to the correct departments.

Per California Code of Regulations, Title 22 deficiencies were observed and are being cited during today's case management inspection. See 9099D Page.

An exit interview was conducted and a copy of this report was given. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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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Document Has Been Signed on 03/15/2024 12:49 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) 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; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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 Executive director Marie Arbios. Has already provided training to staff regarding reporting requirements. No further action is needed at this time.
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This requirement is not met as evidence by Based on records reviewed and interview with executive director Marie Arbios.The licensee did not ensure that the facility provided a written report to licensing for the multiple incidents at the facility. This is a potential safety risk to residents in care.
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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: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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