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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700367
Report Date: 06/28/2021
Date Signed: 06/28/2021 12:11:07 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: 94DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Larry Potter Administrator TIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPA's) Sarah Hurt and Ruth Wallace arrived at Dale Commons facility at 09:00 am on June 28,2021. LPA's met with Administrator Larry Potter. There are currently 94 residents who reside at this home and there is 5 resident's on hospice at this time. LPA'S inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguishers expire 01/25/2022. Smoke alarms are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 111.0 F degrees. First Aid kit is on site and complete. Toxins are locked.

This facility is operating within the scope of their license. LPA's reviewed 5 resident files. Resident's medical files and medications were reviewed. All resident files review were in compliance. Five staff files reviewed and each had the required criminal record clearances. First Aid and CPR training for each staff was current and staff has current required training hours.

No deficiencies were identified on this inspection.

The administrator provided updated copies of LIC 500 Personnel Report, LIC 309, LIC 308 Designation of Administrative Responsibility, Liability Insurance, LIC 610E the Emergency Disaster Plan if needed, and copy of current Administrator’s Certificate to facility file.

Exit interview conducted with Administrator and copy of report and LIC 858 left at facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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