079200575-9-20-2024-15-AS-KHOS-D9ETMW-20240924145149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:48:13 PM

Unsubstantiated

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
08/26/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240826121316

FACILITY NAME:	COMMONS AT DALLAS RANCH, THE		FACILITY NUMBER:	079200575
ADMINISTRATOR:	BRITTANY KARLINSKI		FACILITY TYPE:	740
ADDRESS:	4751 DALLAS RANCH ROAD		TELEPHONE:	(925) 754-7772
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	123	CENSUS: 109	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Roezi Vermouth, Director of Wellness (MOD)		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Staff did not follow proper COVID-19 control protocols
Staff did not prevent resident from developing pressure injuries while in care
Staff did not properly care for resident’s pressure injuries
Staff did not ensure that facility is free of pests

INVESTIGATION FINDINGS:

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On 09/20/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with the director of Wellness (MOD) to deliver the findings of above allegations. LPA explained the purpose of the visit with MOD.

On 09/05/24 at 3:15PM LPA interviewed staff (ED) and obtained the following documents: Residents’ roster with contact information, Personnel record (LIC500), residents (R1, R2, R3, R4, R5) pre-placement appraisals, admission agreements, Face Sheets, ID/Emergency Information, Needs & services plans, Physician’s reports, Doctors’ orders, Centrally stored medications & medication administration records (MARs), Reappraisals, Incident reports, maintenance/pest control schedules.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240826121316

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: 09/20/2024

NARRATIVE

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Allegation: Staff did not follow proper COVID-19 control protocols
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of staff (ED, S1) and reviewed facility’s spot COVID-19 line list report which showed COVID-19 positive residents and staff from 07/24/24 until 08/28/24. Review of the COVID-19 report showed that 4 staff tested positive for COVID-19 on 07/24,07/26, 7/29, 7/30 in Assisted Living and 2 residents in memory care on 08/02 and 08/05. All reported COVID-19 positive staff and residents were isolated until all symptoms were cleared and showed negative test results. On 09/05/24 at 3:30PM, LPA toured the facility with executive director (ED). LPA observed all on duty staff, visitors and some residents wearing face masks, hand sanitizers available for use in common areas. LPA observed facility clean, odor free and in good repair. LPA observed staff follows their COVID-19 infection control plan daily to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with ED as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed one central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. LPA observed COVID-19 signages posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff, visitors and residents Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged occurred. Therefore, the allegation that staff did not follow proper COVID-19 control protocols is unsubstantiated.

Continued on next page, LIC 9099-C1

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240826121316

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: 09/20/2024

NARRATIVE

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Allegation: Staff did not prevent resident from developing pressure injuries while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of staff (ED) who stated that there are 2 memory care residents (R1, R2) diagnosed with Stage 2 pressure injuries. Review of R1’s needs & services plant dated 05/28/24 and physician’s report dated 06/24/24 show that staff conducts regular status checks on R1 4 times per shift, requires extensive multiple psychosocial interventions due to sundowning behaviors, requires total assist with bathing, dressing, toileting, ambulation to all meals and activities, medications and all transfers for safety. R1’s primary care physician (PCP) ordered home health care team to treat R1’s stage 2 wound on her coccyx twice a week. LPA also reviewed R2’s hospice records from 12/04/23 until current which showed R2’s stage 2 coccyx pressure injury is being treated by home health agency 3 times per week and that care was coordinated with staff with instructions to contact hospice agency immediately for any change in condition observed. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not prevent resident from developing pressure injuries while in care is unsubstantiated.

Allegation: Staff did not properly care for resident’s pressure injuries
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of staff and reviewed resident’s (R1) call logs and incident reports. Review of memory care residents (R1, R2) medical records, assessments and hospice records show that staff provided proper wound care treatment for R1 and R2 as prescribed by their primary care physicians and home health care team. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not properly care for resident’s pressure injuries is unsubstantiated.

Continued on next page, LIC 9099-C2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240826121316

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: 09/20/2024

NARRATIVE

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Allegation: Staff did not ensure that facility is free of pests
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed pest control reports dated 11/14/23, 01/04/24, 01/07/24, 08/02/24 which showed that staff (ED) hired a professional extermination company to treat and fumigate the memory care unit for bed bug re-infestation which originated from one of resident’s recliner and wheelchair on 01/07/24. LPA also interviewed staff (ED, S1) who stated that one memory care resident loves to throw bird seed outside the memory care area close to the open field. Staff confirmed with LPA that 2 mice were observed in the kitchen and one resident's memory care bedroom area. LPA confirmed with staff (ED, S1) that the mice infestation was resolved by plugging the holes in the memory care kitchen and resident’s unit on July 30,2024. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that facility is free of pests is unsubstantiated.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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