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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
577001215
Report Date:
07/01/2024
Date Signed:
07/01/2024 04:09:36 PM
Document Has Been Signed on
07/01/2024 04:09 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 DAVIS
FACILITY NUMBER:
577001215
ADMINISTRATOR:
MARIA BURTON
FACILITY TYPE:
741
ADDRESS:
1515 SHASTA DRIVE
TELEPHONE:
(530) 747-7000
CITY:
DAVIS
STATE:
CA
ZIP CODE:
95616
CAPACITY:
500
CENSUS:
33
DATE:
07/01/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:40 PM
MET WITH:
Christie Dewar, AL/MSU Resident Care Manager
TIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a case management inspection regarding an incident report submitted to Community Care Licensing (CCL) received on 6/14/2024.
On 6/11/2024 resident R1 was found by staff outside of building at 4:50 AM beside an overturned wheelchair. Staff contacted emergency services and family was notified. R1 was tranported to hospital.
LPA requested medical records and documentation regarding R1's assessment and care plan. LPA to follow up with Administrator at a later time.
No citations issued at the time of inspection.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Jill Nakagawa
TELEPHONE:
707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE:
07/01/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/01/2024
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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