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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 05/15/2025
Date Signed: 05/15/2025 03:13:17 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
05/13/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250513092441
FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:FRANCINE TAITANOFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 105DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Francine Taitano, Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff administered unauthorized medication to a resident while in care
Staff disclosed personal information about a resident
INVESTIGATION FINDINGS:
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On 05/15/25 at 1:57PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with staff (ED, S1), gathered information relevant to the allegations and delivered investigation findings to ED. LPA explained the purpose of the visit with ED.

During investigation, LPA obtained the following documents from ED: Resident roster, Staff roster (LIC 500), R1's admission agreement, Needs & Services Plan, Physician's report, Centrally stored medication logs, Medication administration records.

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: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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-20250513092441
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: 05/15/2025
NARRATIVE
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Allegation: Staff administered unauthorized medication to a resident while in care
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff (ED, S1) and reviewed assisted living resident (R1) documents. S1 confirmed with LPA that she administered unauthorized medication belonging to another staff to R1 while in care because R1's prescription refill from the pharmacy was delayed. Review of R1’s medication administration records showed R1 received unauthorized medication on 04/16/25 at 12PM. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff administered unauthorized medication to a resident while in care was found to be substantiated.

Allegation: Staff disclosed personal information about a resident
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff (ED, S1) and reviewed resident (R1) documents. S1 confirmed with LPA that she publicly discussed R1's medication with another staff on 04/16/25 in the open area close to the medication room which was adjacent to the visitor's living room/gaming area. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff disclosed personal information about a resident was found to be substantiated.

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

Exit interview conducted, appeal rights and copy of report provided.

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

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250513092441
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: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2025
Section Cited
CCR
87465(c)(2)
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Once ordered by the physician the medication is given according to the physician's directions.
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Executive Director agrees to complete and submit to CCLD in-service staff re-training certifications on proper administration of medications in compliance with Section 87465 regulations.
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This requirement was not met as evidenced by staff administering unauthorized medication to a resident which posed a potential health & safety risk to resident in care.
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Type B
05/30/2025
Section Cited
CCR
87468,2(a)(2)
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To have their records and personal information remain confidential and to approve their release, except as authorized by law
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Executive Director agreed to complete and submit to CCLD in-service staff retraining certifications on personal rights of residents in compliance with Section 87468.2 regulations.
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This requirement was not met as evidenced by staff publicly disclosing resident's personal information 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: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3