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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200575
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:16:57 PM


Document Has Been Signed on 08/01/2024 02:16 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:BRITTANY KARLINSKIFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 103DATE:
08/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Brittany Karlinski, Executive DirectorTIME COMPLETED:
02:30 PM
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On 08/01/2024 at 1:00 PM , Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/18/2024. LPA met with Executive Director (ED), Brittany Karlinski and explained the purpose of the visit.

The incident report received stated that Resident (R1) has been delinquent with their monthly rent since their move-in date. The incident report indicated that the resident's Responsible Party (RP) was offered payment arrangements. However, RP has continued to not make the monthly payments by the due dates.

LPA interviewed Staff (S1) that stated the community offered two (2) payment plans and that the payments continued to be missed payments. S1 stated that payments are due on the 1st of each month and late fees are assessed after the 5th of each month. In addition, S1 stated that RP also has not complied with the payment plans that was offered.

LPA obtained a copy of R1's Admission Agreement and Resident Detail Ledger for 12/29/2023 thru 04/04/2024.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
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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