<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700367
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:30:03 PM


Document Has Been Signed on 05/05/2023 03:30 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:DALE COMMONSFACILITY NUMBER:
502700367
ADMINISTRATOR:POTTER, LARRYFACILITY TYPE:
740
ADDRESS:3900 DALE RDTELEPHONE:
(209) 526-2053
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:110CENSUS: 89DATE:
05/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Stephanie JuddTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/05/23, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced case management visit to this facility. LPA identified herself and the purpose of her visit upon arrival. LPA met with the designated facility administrator, Stephanie Judd. LPA and the designated facility administrator reviewed and discussed incident reports sent to Community Care Licensing dating back to January 2023.

3 resident files were reviewed. LPA focused on physicians' reports, appraisals and assessments as well as 25 incident reports selected from February 2023 to April 2023.

Discussed potential increase in hospice waiver.

Discussed annual appraisals of residents.

Exit interview with Stephanie Judd.
Copy of report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1