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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700368
Report Date: 01/30/2023
Date Signed: 01/30/2023 01:44:45 PM


Document Has Been Signed on 01/30/2023 01:44 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: 97DATE:
01/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:ARBIOS, MARIETIME COMPLETED:
11:30 AM
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On 01/30/23 at 09:45 am Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility for the purpose of conducting a case management incident inspection regarding incident report received dated 01/27/23. LPA explained purpose of visit to the administrator.

LPA reviewed R1'S file and took copies of the Physician's Report (602), COVID testing and charting notes.

LPA Lewis requested administrator contact family and obtain a copy of the death certificate when available and email to LPA Lewis. Kesha.Lewis@dss.ca.gov

R1 tested positive on 02/16/2022 for COVID-19 but not since then.

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 will be emailed to administrator as LPA'S printer is not working at this time.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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