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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 08/19/2022
Date Signed: 08/19/2022 05:11:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20201106113845
FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:ANDREWS, BRITANNYFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 92DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
04:17 PM
MET WITH:Brittany Karlinski, AdministratorTIME COMPLETED:
05:50 PM
ALLEGATION(S):
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Licensee did not provide basic services to residents in care
Insufficient staff to meet residents' needs
Licensee did not assist residents with incontinence care
Residents' medications are not administered as prescribed by physician
INVESTIGATION FINDINGS:
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On 08/19/22 at 4:05PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Licensee did not provide basic services to residents in care
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, residents, authorized representatives and staff expressed concerns regarding residents not receiving basic services such as scheduled showers, assistance with getting out of bed until 11AM to 12PM daily resulting in residents missing their breakfast meals, lack of incontinent care and hoyer lifts being operated by one staff. These issues were acknowledged by former ED to LPA during visit due to short staffing. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20201106113845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: COMMONS AT DALLAS RANCH, THE
FACILITY NUMBER: 079200575
VISIT DATE: 08/19/2022
NARRATIVE
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Allegation: Insuffiicient staff to meet residents’ needs
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, facility failed to meet the needs of the residents due to being short staffed. Residents, authorized representatives and staff expressed concerns regarding residents not being changed in a timely manner, not getting food or late, getting residents up late, not receiving their scheduled showers and not getting medications on time. These issues were acknowledged by former ED to LPA during visit on 11/10/2020. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Licensee did not assist residents with incontinent care


Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, authorized representative (W1) stated that she found resident (R1) soaking wet in bed because she has not been changed. S1 stated that many residents go all day without getting changed or are not wiped well resulting in residents and their rooms smelling. Residents, authorized representatives and staff have complained to former ED and supervisor about these issues with no resolutions. Former ED acknowledged these issues with LPA during visit on 11/10/2020. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Residents’ medications are not administered as prescribed by physician


Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, authorized representative (W2) stated she was with resident (R2) on the weekend of Thanksgiving 2020. She noticed that the pill packs for one of his medications were missing which should have been documented on his medication list. W2 discussed the issue with former ED and nurse supervisor. They confirmed R2 has not been receiving his daily stool softener medication. Per W2, it was only after a week that the ‘paperwork” was found documenting that he was prescribed the stool softener medication daily and after that he received it regularly. Former ED acknowledged this incident during visit on 11/10/2020. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20201106113845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMONS AT DALLAS RANCH, THE
FACILITY NUMBER: 079200575
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
HSC
1569.2(c)
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(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
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By POC due date, administrator agreed to complete and submit to CCLD a copy of in-service staff retraining certifications by an approved CCLD vendor on assistance with activities of daily living in compliance with Title 22 Health & Safety Code Section 1569.2
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This requirement was not met as evidenced by staff failing to provide basic services which posed a potential health & safety risk to residents in care
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Type B
09/02/2022
Section Cited
CCR
87413(a)(1)
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When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks
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By POC due date, administrator agreed to complete and submit to CCLD a copy of updated personnel record showing sufficient staff working in each shift as well as copies of staff retraining certifications by an approved CCLD vendor on proper care and supervision of residents in compliance with Title 22 Section 87411 regulations.
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This requirement was not met as evidenced by insufficient staff which posed a potential health & safety risk to residents in care.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20201106113845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMONS AT DALLAS RANCH, THE
FACILITY NUMBER: 079200575
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
CCR
87625(b)(3)
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Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by staff failing to assist residents with
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By POC due date, administrator agreed to complete and submit to CCLD a copy of in-service staff retraining certifications by an approved CCLD vendor on managing incontinence in compliance with Title 22 Section 87625 regulations.
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incontinence care which posed a potential health & safety risk to residents in care.
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Type B
09/02/2022
Section Cited
CCR
87465(b)
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If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication
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By POC due date, administrator agreed to complete and submit to CCLD a copy of in-service staff retraining certifications by an approved CCLD vendor on incidental medical and dental care in compliance with Title 22 Section 87465 regulations.
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This requirement was not met as evidenced by staff failing to administer residents' medications as prescribed which posed a potential health & safety risk to residents in care.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20201106113845

FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:ANDREWS, BRITANNYFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 92DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
04:17 PM
MET WITH:Brittany Karlinski, AdministratorTIME COMPLETED:
05:50 PM
ALLEGATION(S):
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3
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Staff verbally abuse residents
INVESTIGATION FINDINGS:
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On 08/19/22 at 4:05PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Staff verbally abuse residents
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, staff denied verbally abusing residents. Resident (R2) stated he has never experienced nor observed any mistreatment of the residents at the facility. Witness (W1) stated resident (R3) never complained of any abusive behavior by staff towards her. Staff denied verbally abusing residents. Resident Services Director told LPA any staff verbally abusing any resident would be immediately terminated due to violation of company policy.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report provided via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5