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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700367
Report Date: 04/22/2021
Date Signed: 04/22/2021 04:23:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DALE COMMONSFACILITY NUMBER:
502700367
ADMINISTRATOR:POTTER, LARRYFACILITY TYPE:
740
ADDRESS:3900 DALE RDTELEPHONE:
(209) 526-2053
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:110CENSUS: 90DATE:
04/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Assisted Living Manager, Alexis Alvarez TIME COMPLETED:
04:00 PM
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On 4/22/2021, Licensing Program Analyst (LPA) Jason Lund contacted the facility to complete a case management via telephone due to COVID-19 and pre-cautionary measures. LPA Lund discussed the purpose of the call with Assisted Living Manager, Alexis Alvarez. Current Census 90

On 4/12/2021 Community Care Licensing received an Unusual Incident/Injury Report regarding Resident (R1). R1 was on hospice since moving to the facility but was ambulatory and sociable. On 4/6/2021 R1 had an unwitnessed fall and was sent to the hospital with injuries to the head and hip. R1 was recovering from surgery and R1 family called and stated to the facility that R1 had passed away on 4/11/2021. R1 had no history of falls and death report will be emailed to LPA when available.

Exit interview was conducted with Alexis copy of report provided via email due to COVID 19 precautionary measures, with a read receipt to verify it was received.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
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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