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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700366
Report Date: 06/17/2026
Date Signed: 06/17/2026 03:45:10 PM

Document Has Been Signed on 06/17/2026 03:45 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR/
DIRECTOR:		JOSHUA LAMBENGCOFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 135CENSUS: 103DATE:
06/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Carli FloresTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On June 17,2026, Licensing Program Analysts (LPA) Melina Oropeza and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by Business Office Director, Admin is on vacation. LPA explained the purpose of the visit,

LPM observed breakfast service in the main dining room consisting of corn beef hash, fruit and cereal. The menus were accessible on the dining tables of AL. The environment was clean and inviting.


LPM and LPA conducted a tour of the Memory Care (MC) area. The general area was clean with no odor, breakfast service was finished and residents were seated in different areas of the community. Residents appeared well kept. LPM conversed with several residents throughout the MC, all appeared pleasant and engaged. LPM entered 5 resident rooms 5/5 (R6, R7, R8, R9, R10) had personal care supplies and 1/5 had cleaning supplies accessible (this room was locked and resident manages key to room) and reviewed the LIC602 for these residents. 2 of 5 are at risk if allowed access to personal care and/or cleaning supplies. TA was provided that although 1 of 5 is allowed access per the LIC602, it may benefit the community to have the resident reassessed, the LPM observed a coffee cup full of shaving cream which could be ingested. Additionally, TA was provided to develop a plan to assist staff in identifying those residents there are and are/not allowed access to dangerous substances. LPM pulled a cord in R9s room which was answered in one minute. R10 has their own refrigerator in their room which contained expired foods. Late morning activities in MC were observed, residents were engaged in singing and Fit and Fun.
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NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Melina Oropeza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMMONS AT UNION RANCH, THE
FACILITY NUMBER: 392700366
VISIT DATE: 06/17/2026
NARRATIVE
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LPA reviewed 5 MC resident files (R1, R2, R3, R4, R5) with no concerns.

LPM followed up incident reports while at the facility for R3, R6.
R3 has experienced 5 falls from March to current. Prior assessment documented resident as independent updates have been made to provide stand by assist to full assist. R6 had 12 falls over a 1 month period, updates to the Care plan have been made and family is informed. A review of these 2 resident MARs was conducted, R6 was provided a prn on two occasions, discussion occurred related to pain management or possible discomfort associated with pain which may have attributed to the number of falls. A standing order for pain management following several falls may have been implemented had the resident had a medical assessment or contact made with the PCP. Additional conversation occurred related to the facility policy regarding unwitnessed falls in the MC area, families refusal for medical evaluation and the facilities liability if an injury or change in condition occurs and medical assessment was not sought. Additionally, according to the facility representative if emergency response is contacted, they do not leave documentation of refusal of medical treatment if family refuses over the phone.
MARS did reveal that the facility is documenting medications not available and residents are going without prescribed medications for a period of time. Discussion occurred with the MCD and a MT re facility practice and obligation to provide meds as ordered and bill back the resident.
Fire Extinguishers are monitored monthly by staff and last serviced on 04/15/2026. Water temp within regulation at 110 degrees.
Assisted Living (AL) was observed in the afternoon. Residents were engaged in arts activities prior to lunch and some residents went on a restaurant outing. Five resident files were reviewed from AL, 4/5 (R14, R15, R13, R12) functional assessment portion of the preplacement appraisal was incomplete or not signed. Three resident MARS for AL were reviewed, same concerns. A tour of AL was conducted incl. kitchen, dinning room, resident areas and 2 resident bedrooms - no concerns. Stairwells were clear and within regulation. Ancillary system and fire extinguishers in the area were serviced in 2026. Adequate food available including snacks and water stations throughout.
LPM reviewed two resident council meeting notes, Emergency preparedeness, fire drills care staff in-service notes with no concerns. LPA and LPM reviewed 11 staff files with no concerns.
Exit interview held with staff and copies of reports left at conclusion of visit.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Melina Oropeza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMMONS AT UNION RANCH, THE
FACILITY NUMBER: 392700366
VISIT DATE: 06/17/2026
NARRATIVE
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Citations are issued during todays visit and referenced on the 809D page. An exit interview was conducted with the Director of Health Services, the report, citations and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Melina Oropeza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2026 03:45 PM - It Cannot Be Edited


Created By: Melina Oropeza On 06/17/2026 at 02:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT UNION RANCH, THE
FACILITY NUMBER: 392700366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 4/5 AL resident files reviewed the preplacement appraisal was incomplete. This poses a potential risk to clients in care.
POC Due Date: 07/18/2026
Plan of Correction
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The facility will do an internal audit of the preplacement appraisal documents within 30 days
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Melina Oropeza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2026 03:45 PM - It Cannot Be Edited


Created By: Melina Oropeza On 06/17/2026 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT UNION RANCH, THE
FACILITY NUMBER: 392700366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Based on review of MARS and interview with staff, when a resident runs out of medication it is documented on the MAR as "Medication not available", sometimes for several weeks. This poses an immediate threat to the H&S of residents in care.
POC Due Date: 06/18/2026
Plan of Correction
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DHS will Provide documentation of training to all Med Techs of facilities regarding practice for ordering medications when they have not been filled by the RP or resident. This alert should be signed by the MT and copies email to Melina.Oropeza@dss.ca.gov by 5:00pm on June 18, 2026.
Type A
Section Cited
CCR
87309(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
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(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. Based on tour of the facility, photographs taken and interview with staff 2of5 MC resident rooms contained personal care supplies accessible to those in care although the residents LIC602 documented that the resident would be at risk if allowed access. This poses an immediate H&S concern for those in care.
POC Due Date: 06/17/2026
Plan of Correction
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Items removed during visit no POC needed. hOWEVER, Facility should provide an in-service to all caregivers regarding this regulation and best practices in the community.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Melina Oropeza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2026


LIC809 (FAS) - (06/04)
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