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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700367
Report Date: 07/05/2023
Date Signed: 07/07/2023 09:15:57 AM


Document Has Been Signed on 07/07/2023 09:15 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:DALE COMMONSFACILITY NUMBER:
502700367
ADMINISTRATOR:POTTER, LARRYFACILITY TYPE:
740
ADDRESS:3900 DALE RDTELEPHONE:
(209) 526-2053
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:110CENSUS: 89DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Larry Potter, Administrator, Stephanie Judd, Director TIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Kimberly Viarella conducted an unannounced visit today for the facility’s annual inspection. LPA met with the Designated Facility Administrator Larry Potter (Administrator Certificate # 6007187740, expiration 06/29/23. Proof of renewal application and paid fees was provided and dated 04/19/23.) LPA also met with the Director of Wellness, Stephanie Judd. The LPA explained the reason for the visit and conducted a brief interview. Census was 89 residents in care, with a hospice waiver for 10 at this time.

This facility is licensed for the following: NON AMB/BEDRIDDEN CLIENTS PERMITTED IN RM’S 239-259 ON THE SECOND FLOOR AS 2 VERTICAL EXIT ENCLOSURES ARE PROVIDED. ROOMS ON THE GROUND FLOOR ARE PERMITTED FOR BEDRIDDEN/NON-AMB A PERMANENT BASIS/MORE THAN 14 DAYS. Client Groups Served: ELDERLY

The facility was not designed to separate individuals based on their levels of care and offered services to residents living independently needing no or little assistance from staff, as well as those who required assistance with activities of daily living. There were also residents with dementia, however the facility did not have a memory care unit/neighborhood and they received their services within the larger facility community as did the residents on hospice.

The Designated Facility Administrator began the tour in the kitchen. The fire extinguisher was inspected on 06/21/2023, by Jorgensen Co. The hood was inspected 04/2023. Food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated. A storage container of Thick It was dated 06/01/22 which indicated when it was opened and shelved. This LPA noted that there was no expiration date. The Executive Chef called the manufacturer and was told that the product had a shelf life of 2 years after being opened. He added the expiration date to the container.

This inspection will be continued on 07/06/2023.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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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