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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700367
Report Date: 07/06/2023
Date Signed: 07/07/2023 09:32:25 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/07/2023 09:32 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:
07/06/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Larry Potter, Administrator, Stephanie Judd, DirectorTIME COMPLETED:
05:15 PM
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Annual Continued...
The LPA inspected the medication room, the CMDR and the Destruction Log. All medications and documentation were in compliance. This facility scheduled a medication audit to be preformed in July by PharmAmerica. Med Techs utilized 4 locked medication carts which were stored in the locked nurse’s office when not in use. LPA examined the medications in both the medication room and the carts, and all were in compliance. LPA reviewed medication storage, distribution, and the destruction processes. Each cart contained a First Aid kit. LPA observed that all required items were included.
The LPA inspected all common areas: activity rooms, exercise room, dining room, Bistro, laundry rooms. All had adequate furniture/furnishings and lighting to be in compliance. Scheduled activities were posted and LPA observed Bingo, exercise classes, and board games at various times. LPA inspected resident rooms on both the first and second floor and all were in compliance.
The Designated Administrator escorted the LPA around the perimeter of the facility for an exterior inspection. LPA observed several covered patio areas for residents to enjoy along with recently repaired concrete walkways. LPA did note that 12 window screens needed to repaired/replaced. The Designated Facility Administrator stated that he already had some on order and they would be replaced by 07/31/23..
A file review was completed for both residents and staff. Technical Assistance was offered but no deficiencies were cited in these areas. One employee was not associated to the facility but this was rectified by the business office manager as soon as they were informed.
There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA's requested the following documents: LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and an updated copy of the facility liability insurance.

Exit interview conducted with the Designated Facility Administrator Larry Potter and copy of report left at facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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