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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700368
Report Date: 12/12/2022
Date Signed: 12/12/2022 11:57:27 AM


Document Has Been Signed on 12/12/2022 11:57 AM - 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: 100DATE:
12/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ARBIOS, MARIETIME COMPLETED:
12:15 PM
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On 12/12/22 at 10:00 am Licensing Program Analysts (LPA'S) Kesha Lewis and Albert Johnson arrived at the facility for the purpose of conducting a case management incident inspection regarding incident reports received dated 11/02/22, 11/15/22, 11/15/22,/11,23/22.

LPA explained purpose of visit to the administrator.

Based on records reviewed, R1 is marked as not a fall risk but has had multiple falls before the assessment was done on 11/22/2022, Falls- 11/15/22, 11/15/22,11/16/22, and a fall after the assessment was done on 11/29/22 (copies taken of fall reports). The responsible party for R1 is looking for a higher level of care. (copy taken of physician visit form). Falls are addressed in the needs and services plan. The facility has a loss prevention program in place (copy taken).

Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection.

An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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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