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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:50:37 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
06/01/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220601113637
FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:MICAH SAVAGEFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 90DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Brittany Karlinski, Executive DirectorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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9
Facility staff did not seek timely medical attention for resident.
Resident care needs not being met.
Facility staff did not administer medication timely
INVESTIGATION FINDINGS:
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On 11/1/22 at 9:15am, Licensing Program Analyst (LPA) C. Lin arrived unannounced a subsequent complaint investigation regarding the above allegations and deliver investigation findings. LPA met with Executive Director and informed the purpose of visit.

Allegation: Facility staff did not seek timely medical attention for resident – Unsubstantiated
The Department has investigated this allegation and per records review and interviews and found that hospice order should not be handled by facility staff. Facility staff could coordinate hospice order with hospice agency but should not take responsibility.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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 2
Control Number 15-AS-20220601113637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 079200575
VISIT DATE: 11/01/2022
NARRATIVE
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Allegation: Resident care needs not being met – Unsubstantiated
The Department has investigated this allegation and per records review and interviews and found that facility staff assisted resident to self-administer medication, inappropriate interaction to R1 was not witnessed or observed by other staff in subject time period or at other time.

Allegation: Facility staff did not administer medication timely – unsubstantiated
The Department has investigated this allegation and per records review and interviews and found that facility staff should not administer medication Morphine to resident. The Hospice Care Plan clearly indicated that “Do not use until directed by hospice”.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit interview conducted with Executive Director and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2