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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577001215
Report Date: 06/07/2022
Date Signed: 06/07/2022 04:25:25 PM


Document Has Been Signed on 06/07/2022 04:25 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
06/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria Burton, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced case management and met with Maria Burton, Administrator. The purpose of this case management inspection is to follow up on an incident report submitted to Community Care Licensing (CCL).

The incident was received on 5/20/22 when Client (C1) reported that jewelry was missing from apartment.
Staff contacted the resident. LPA requested the signed inventory list of the resident. No items were recorded; form was signed by resident. Administration filed an SOC 341, the Ombudsman and APS were notified. Information from Police Report has not been received. Family was notified.

LPA has requested a call back from the resident or permission by the resident for LPA to call, as well as follow-up with Police Department and Ombudsman.


SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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