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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577001215
Report Date: 12/03/2021
Date Signed: 12/03/2021 03:17:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:UNIVERSITY RETIREMENT COMMUNITY AT DAVISFACILITY NUMBER:
577001215
ADMINISTRATOR:MARIA BURTONFACILITY TYPE:
741
ADDRESS:1515 SHASTA DRIVETELEPHONE:
(530) 747-7000
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:500CENSUS: DATE:
12/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Maria Burton, AdministratorTIME COMPLETED:
03:15 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
Licensing Program Analyst Jill Nakagawa arrived unannounced at University Retirement Community at Davis to conduct an investigation regarding an incident involving the unauthorized/illegal use of a resident's credit card information. Administrator Maria Burton filed an SOC 341 as soon as the incident was reported. Davis Police, the Ombudsman's Office of Yolo County and APS were also notified.

The resident filed a police report with Davis Police Department.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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