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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700367
Report Date: 09/21/2026
Date Signed: 09/22/2026 09:32:08 AM

Document Has Been Signed on 09/22/2026 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DALE COMMONSFACILITY NUMBER:
502700367
ADMINISTRATOR/
DIRECTOR:		HOLGUIN, PATRICIAFACILITY TYPE:
740
ADDRESS:3900 DALE RDTELEPHONE:
(209) 526-2053
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 110CENSUS: 91DATE:
09/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Patricia HolguinTIME VISIT/
INSPECTION COMPLETED:
04:30 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
Unannounced annual visit made out to this facility on 09/21/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Patricia Holguin, who was briefly interviewed at this time.
It was learned that there were (7) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (15) residents at any given time.
It was learned that there were (7) residents diagnosed with dementia at this time. This facility does have an approved program to be able to accept and retain residents diagnosed with dementia at any given time.
This facility does not have a dedicated memory care unit on site at this time.
Current census was 91 residents.
Tour of the facility was conducted.
A tour of the facility kitchen area was conducted. Food storage units, refrigerators and freezers, were toured. It was observed that there was a sufficient supply of 2-day perishable food quantities available on site to meet the requirements at this time.
Pantry area was toured. It was observed that there was a sufficient supply of 7-day nonperishable food quantities available on site to meet the requirements at this time.
A sample review was conducted for the facility resident bedrooms at this time. It was observed that furniture and furnishings were observed to be functional and maintained in compliance at this time.
A sample review was conducted for the facility resident restrooms at this time. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Grab bars and non skid surfaces were observed to be present and maintained in compliance at this time.
Living areas, dining areas, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Liza King
Charlie Yang
DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2026
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 7
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: 09/21/2026
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
26
27
28
29
30
31
32
Laundry rooms were toured. They were observed to be made available to the facility residents who chose to perform their own laundry without the presence of laundry detergents, bleach, and supplies at this time.
Rooms designated as supply rooms, storage rooms, and equipment rooms were observed to be locked and made inaccessible to the residents at this time.
Medication carts were reviewed alongside the facility designated Administrator and present medication technician. Policies and procedures in regards to the handling, dispensing, and documentation of the resident medications were discussed at this time. This facility utilized mobile medication carts that were pushed out into the facility when it was time to dispense the medications to the residents.
It was learned that this facility employed an E-MAR system as well as documented paperwork for the facility resident medications at this time.
First aid kits, located in the medication carts, were observed to contain all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Jorgensen Co., on 03/27/2026 and found to be in compliance at this time.
A tour of the facility exterior grounds was conducted. A review of the perimeter fence, side gates, and all other exits was conducted at this time.

A review of (10) facility resident files was conducted and noted on the following LIC 858.
A review of (10) facility personnel files was conducted and noted on the following LIC 859.
The following forms and documents were requested by this LPA to be updated and submitted into CCL:
LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/22/2026 09:32 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/21/2026 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DALE COMMONS
FACILITY NUMBER: 502700367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(d)(1)
Storage Space and Access
(d) Residents may have access to items specified in subsection (c) for personal use unless there is documentation as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. (1) The licensee shall implement reasonable interventions in order to ensure that access to the items specified in subsection (c) does not pose a hazard to other residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that cleaners and other cleaning agents were found present in resident bedrooms and restrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2026
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all cleaners and cleaning agents will be reviewed and removed if residents are deemed unable to self manage and store within the confines of their rooms as stated on the most recent LIC 602. A statement of correction, along with proof of removal from resident bedrooms with accounts of items removed, will be completed and submitted into CCL by the due date for review by this LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/22/2026 09:32 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/21/2026 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DALE COMMONS
FACILITY NUMBER: 502700367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in there was a window which was cracked with a split extending from the top towards the bottom of the window which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2026
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all windows will be reviewed and audited to make sure that they are all in good repair at tall times. A statement of correction, along with proof of contracted services to repair/replace the broken window, will be completed and submitted into CCL by the due date for review by this LPA.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in several window screens had holes, rips, or tears in them which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2026
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all window screens will be reviewed and audited to make sure that they are all in good repair at tall times. A statement of correction, along with proof of contracted services to repair/replace the window screens, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/22/2026 09:32 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/21/2026 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DALE COMMONS
FACILITY NUMBER: 502700367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that facility personnel records were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2026
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility personnel records will be reviewed and audited to make sure that they are complete and in compliance at all times. A statement of correction, along with proof of updated facility personnel records, will be completed and submitted into CCL by the due date for review by this LPA.
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that facility personnel records did not show required updated staff training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2026
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility personnel records will be reviewed and audited to make sure that they are complete with all required hours of annual training and in compliance at all times. A statement of correction, along with proof of updated facility personnel records for annual training, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/22/2026 09:32 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/21/2026 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DALE COMMONS
FACILITY NUMBER: 502700367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that facility resident records were incomplete missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2026
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility resident records will be reviewed and audited to make sure that they are complete and in compliance at all times. A statement of correction, along with proof of updated facility resident records, will be completed and submitted into CCL by the due date for review by this LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2026


LIC809 (FAS) - (06/04)
Page: 7 of 7