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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700368
Report Date: 05/12/2022
Date Signed: 05/13/2022 07:13:05 AM

Document Has Been Signed on 05/13/2022 07:13 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:COMMONS ON THORNTON, THEFACILITY NUMBER:
392700368
ADMINISTRATOR:ARBIOS, MARIEFACILITY TYPE:
740
ADDRESS:10711 THORNTON RDTELEPHONE:
(209) 476-1500
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 110CENSUS: 102DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Marie Arbios, Executive DirectorTIME COMPLETED:
12:35 PM
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PA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by Executive Director Marie Arbios and LPA explained the purpose of the visit and Ms. Arbios accompanied LPA on the facility inspection.

LPA Jacobs inspected the physical plant including but not limited to the kitchen and food supply, dining room, several resident bedrooms, resident bathrooms, laundry area, living area, activities area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. The Memory Care area was also inspected. Facility is a 110 bed facility with a current census of 102. There are 76 residents in assisted living and 26 in the memory area. The entrance area and hallways have COVID precautions in place including social distancing noted. Toxins and medications noted to be locked to residents in care.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility is working on their infection control plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place supplied by Sysco Foods. Resident rooms were sanitary and had the required furniture and furnishings.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COMMONS ON THORNTON, THE
FACILITY NUMBER: 392700368
VISIT DATE: 05/12/2022
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The facility common areas were clean and furnished. Smoke and carbon detectors were tested and are in good repair. Fire extinguishers were serviced on March of 2022 and are in compliance. The facility has operable carbon monoxide and detectors and the smoke detectors were tested are also operational. The facility has a built in sprinkler system alarm system that was tested in April 2022 and is operable. Facility has an emergency food and water supply in a separate storage area in kitchen. Water temperature was tested between 110 and 114 in several residents rooms and is within the required range of 105 to 120 degrees F. First Aid kit is on-site and was checked. All staff on-site have current fingerprint clearances. Administrator's Certification for Marie Arbios is current.

LPA requested the following documents to be updated: LIC 500 and LIC 309 have been received in March 2022. No deficiencies were observed during this visit

Exit interview was held and a report was given to Ms. Arbios
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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