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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700367
Report Date: 06/25/2024
Date Signed: 06/25/2024 03:35:51 PM


Document Has Been Signed on 06/25/2024 03:35 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Larry PotterTIME COMPLETED:
03:45 PM
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On 6/25/24 at approximately 9:50am Licensing Program Analysts (LPAs) Maja Jensen and Kesha Lewis arrived at facility unannounced to conduct a required 1 year annual visit. LPAs Jensen and Lewis met with Executive Director Larry Potter and explained the purpose of today's visit.

LPA Jensen and Lewis toured the facility grounds. All paths were free of obstruction. The grounds were observed to be well maintained. There is a large fountain at the front entrance but no bodies of water on the property. All window screens were in observed to be in good repair. There is outdoor furniture available client and guest use. LPA Jensen toured the physical plant interior. The facility was observed to be sanitary and free of odor. All furniture was in good repair. The thermostat was set at 77 degrees Fahrenheit which falls within the required range of 68 - 85 degrees. The bathroom water temperature was measured at 112 degrees Fahrenheit which falls within the required range of 105 - 120 degrees Fahrenheit. The individual bedroom units contained all required furniture. The individual units have bathroom vanities with locks so that individuals can lock medication if they are able to self administer. The smoke detectors and carbon monoxide detectors were tested and found to be in good working order. The fire extinguisher was last serviced in June of 2024 and is in compliance. The Ansul system which requires semi-annual service was last serviced in April of 2024 and is in compliance. The emergency disaster plan was reviewed and determined to be current and appropriate.

LPA Jensen and Lewis observed lunch service during the course of the visit. The menu listed for the day accurately reflected the meal served. LPA Jensen inspected the kitchen and observed it to be sanitary. There was a 2 day supply of perishable food and a 7 day supply of non-perishable food. All food removed from original packaging was labeled with expiration dates. The refrigerators and freezer were maintained at the appropriate temperature and were sanitary.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DALE COMMONS
FACILITY NUMBER: 502700367
VISIT DATE: 06/25/2024
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There are charts in the dining room with resident photos and food restrictions or dietary preferences listed.

There are a variety of activities available for client engagement. The facility employs a fitness director as well as an activity director and an activity assistant. A total of 7 activities were scheduled for the day including garden club, head to toe stretching, and wheel of fortune. There are large monitors in the common area of the facility that display the activities with times, meal service information and other pertinent information for residents. The same information displayed on the large monitors is available on the TV in the individual bedrooms or on paper. The facility also has a gym, a beauty salon, reading rooms, and a laundry room for resident use. No toxins or medications were observed to be accessible to residents in care.

LPA Jensen and Lewis reviewed 10 staff files and 10 resident files. All files were determined to be complete and in compliance. LPA Jensen interviewed 5 residents and 5 staff members. All residents stated they are satisfied with all aspects of care. All staff members interviewed were adequately able to answer the questions asked. LPA Jensen obtained a current LIC 500 and resident roster.

LPAs Jensen and Lewis left the facility for a meal break period between the hours of 11am and 12pm. The facility was determined to be in substantial compliance. No deficiencies were noted during the course of this inspection. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
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