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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700367
Report Date: 07/10/2025
Date Signed: 07/10/2025 05:13:42 PM

Document Has Been Signed on 07/10/2025 05:13 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/
DIRECTOR:
POTTER, LARRYFACILITY TYPE:
740
ADDRESS:3900 DALE RDTELEPHONE:
(209) 526-2053
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 110CENSUS: 88DATE:
07/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:21 AM
MET WITH:Larry Potter, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:12 PM
NARRATIVE
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On 07/09/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived unannounced at the facility to conduct a required annual inspection. The LPA met with Designated Facility Administrator (DFA) Larry Potter. The LPA introduced herself, explained the purpose of the visit, and conducted an interview with the Administrator. The DFA accompanied the LPA on a tour of the facility.

The facility is a two-story building that is licensed for one hundred and ten residents. The facility has a hospice waiver for fifteen. The census was eighty-eight at the time of this inspection. The facility was remodeled in 2024, including new flooring, paint, and furniture throughout the common areas of the facility. In addition, the upstairs activity area was outfitted with a large screen television and theater chairs, and the staff room was expanded and a kitchenette was added to it.

The DFA began the inspection tour on the first floor in the large dining room located just inside the entry way. The room was carpeted and contained many tables and padded chairs. The room has a high ceiling and is lit by hanging light fixtures and natural light from windows. The LPA observed lunch being served between 11 AM and 1 PM. Service was restaurant style –staff takes residents’ orders at the table and food is delivered to the tables. There is a small adjacent private dining area separated from the main room by windows and a door with glass panes, which can be reserved by residents for private events. The LPA then toured the bistro, a small room near the dining area that has a small food service station and several tables. The dining room and bistro are both used for activities, including bingo, jeopardy, exercise classes, and word games.

This report continues on page 2.

Lisa RiosTELEPHONE: (916) 969-9685
Ellen LindstromTELEPHONE: (916) 809-2109
DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2025
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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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)
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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: 07/10/2025
NARRATIVE
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The LPA observed the front entry desk, a section of which had been lowered during last year’s remodel to be more ADA accessible. Beyond this is a small front room with living room furniture, including couches and chairs, which residents can use to visit, rest, and watch television.

Also on the first floor, the LPA toured a small, locked medicine room, which is used for the storage of overflow, incoming, and refrigerated medications. This room also contained a large first aid kit and a go-bag with first aid supplies. The LPA observed two laundry rooms on the first floor that are for use by residents who do their own laundry. There is also a fitness center and a commercial laundry on the first floor.

While touring the hallways, the LPA observed multiple fire extinguishers, smoke detectors, and a sprinkler system, all of which were serviced by Jorgensen Company of Modesto on June 18, 2025. The facility used Universal Fire to monitor its alarms and notify the fire department. The DFA stated that the facility does disaster drills once a month for all three shifts, including for fire and earthquakes.

The LPA observed two medication carts located downstairs in hallways. The medication carts contained resident medication. The carts locked and unlocked with a keypad, and drawers automatically lock when closed. The LPA interviewed a Med Tech and reviewed the facility’s electronic medication administration record and paperbased logs, and determined that medications and documentation were in compliance.

The LPA toured the kitchen. The floors, walls, equipment, shelves, and appliances were clean. The hood was last serviced in April 2025 by Certified Kitchen Exhaust Cleaner. The LPA observed a food supply that was adequate for 2-day perishable and 7-day nonperishable in the refrigerators, freezer, and dry storage pantry.

The LPA toured the upstairs of the facility. There are four staircases and one elevator between floors. The LPA observed evacuation chairs in the stairways and a certificate in the elevator from its last service on 11/25/2024. The LPA toured the beauty salon, activity area with its new seating and television, and a library with a sitting area, computer desks and a water station. The LPA observed two more med carts in the hallways and two more resident laundry rooms.

The LPA observed three resident bedrooms. The bedrooms are clean, pest and odor-free, and have the required furniture. The LPA measured hot water in a resident sink at 124 degrees Fahrenheit, which is outside of the required temperature range of 85 to 120 degrees. The DFA corrected this during the visit.

This report continues on page 3.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Ellen LindstromTELEPHONE: (916) 809-2109
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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: 07/10/2025
NARRATIVE
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The LPA toured the grounds, which consist of manicured grass lawns and ornamental bushes. The concrete walkways are free of obstructions. The backyard, accessed through the bistro, contained shade structures and seating for residents. There were also raised beds and a putting green.

The LPA reviewed seven resident files and nine client files. All files were in compliance.

The entire facility clean, odor and pest free, and had the required furniture. The LPA observed residents engaged in activities and socializing over meals.

The LPA requested that updated copies of these documents be submitted to her by 5:00 PM on 7/28/2025.



(1) LIC 308 Designation of Facility Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Liability Insurance
(6) LIC 500 Personnel Report
(7) LIC 309 Administrative Organization

As a result of this inspection, the facility was not in compliance with California Code of Regulations (CCR), Title 22, Division 6. A deficiency was cited. The DFA corrected the deficiency during the site inspection by adjusting the water heaters. Please see the LIC 809D report for citations related to the deficiency observed during the inspection.

An exit interview was conducted with the DFA, to whom copies of this LIC809 report, the LIC 809D, and the appeals rights were provided. Their signature below confirms receipt of this document.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Ellen LindstromTELEPHONE: (916) 809-2109
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2025 05:13 PM - It Cannot Be Edited


Created By: Ellen Lindstrom On 07/10/2025 at 04:35 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: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303(e)(2) Faucets used by residents for personal care...shall deliver hot water...maintained to...a temperature of not less than 105 degree F and not more than 120 degree F.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as the water temperature in a resident's bathroom sink measured 124 degrees Fahrenheit, which poses an immediate health and safety to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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The DFA turned down the water heaters during the site inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 969-9685
Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 809-2109
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
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