<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 12/29/2022
Date Signed: 12/29/2022 01:41:16 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
09/19/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220919155522
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: 90DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Diane Taylor, Interim Health DirectorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mishandled a resident's medication while in care
Staff did not seek timely medical attention for a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/29/22 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with interim Health Director (IHD) to deliver the findings of above allegations. LPA explained the purpose of the visit with IHD.

Allegation: Staff mishandled a resident’s medication while in care
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, resident’s (R1) medication was ordered discontinued on 09/01/22. However, med tech on duty administered a double dose (2mg) of the medication to R1 in error for 14 days because the facility’s medication administration system (QuickMar) was not updated as discontinued on 09/01/22 and the medication was left in the med cart. 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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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 3
Control Number 15-AS-20220919155522
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: 12/29/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff did not seek timely medical attention for a resident
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, Executive Director (ED) confirmed with LPA that resident’s (R1) medication was ordered discontinued on 09/01/22. R1 was admitted to hospice care at the facility on 08/09/22. Staff notified R1’s hospice nurse about the medication error on 09/09/22 and an updated med list was requested. Hospice nurse visited R1 the same day and found R1’s vital signs good. However, R1 was administered a double dosage of the medication until 9/15/22 when the medication error was discovered by staff. R1’s family was notified by staff of the medication error on 09/17/22. Based on interviews and record reviews conducted, the allegation that staff did not seek timely medical attention for R1 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.

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

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220919155522
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: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
12/29/2022
Section Cited
CCR
87465(e)
1
2
3
4
5
6
7
For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication…
1
2
3
4
5
6
7
Deficiency corrected on 09/22/22. ED conducted an internal investigation and terminated 3 staff due to neglect of duties and violation of company regulations.
8
9
10
11
12
13
14
This requirement was not met as evidenced by staff mishandling resident's medication which posed an immediate health & safety risk to resident in care.
8
9
10
11
12
13
14
In-service staff retraining on residents’ incidental medical and dental care was conducted in August and September 2022.
Deficiency Dismissed
Type A
12/29/2022
Section Cited
CCR
87465(c)(1)
1
2
3
4
5
6
7
There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation...
1
2
3
4
5
6
7
Deficiency corrected on 09/22/22.
ED conducted an internal investigation and terminated 3 staff for neglect of duties and violation of company policies.
8
9
10
11
12
13
14
This requirement was not met as evidenced by staff failing to timely seek medical attention to resident which posed an immediate health & safety risk to resident in care.
8
9
10
11
12
13
14
In-service staff retraining on mandatory reporting requirements was conducted in August and September 2022.
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: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3