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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:51:48 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
08/02/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210802081302
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: 86DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Brittany Karlinski, Executive DirectorTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Staff are not cleaning residents room
INVESTIGATION FINDINGS:
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On 1/12/2023 at 9:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings. LPA met with Executive Director, Brittany Karlinski.

During the course of investigation, LPA interviewed 3 residents, 4 staff, and witness. LPA obtained and reviewed documents including physician's report, care plan, emergency information, care notes, housekeeping checklist, end of shift reports, and housekeeping schedule. Interview with staff indicated that R3's carpet was suppose to the be washed. Interview with resident (R3) revealed that room have not been cleaned. Daily housekeeping checklist from 7/1/2021 to 8/11/2021 did not show R3's room have been cleaned or resident refusal.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 4
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
08/02/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210802081302

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: 86DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Brittany Karlinski, Executive DirectorTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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2
3
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9
Resident left in soiled diapers for an extended period of time
Resident is not receiving showers
Residents room has feces on the carpet
INVESTIGATION FINDINGS:
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On 1/12/2023 at 9:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings. LPA met with Executive Director, Brittany Karlinski.

During the course of investigation, LPA interviewed 3 residents, 4 staff, and witness. LPA obtained and reviewed documents including physician's report, care plan, emergency information, care notes, housekeeping checklist, end of shift reports, and housekeeping schedule.

Resident left in soiled diapers for an extended period of time
Interview with staff indicated that resident would refuse to change diapers and another staff would attempt at a later time. R3 stated that R3 is able to change own diaper. R3's physician's report states that R3 does not have a dementia diagonsis.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20210802081302
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: 01/12/2023
NARRATIVE
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Resident is not receiving showers
Interview with staff indicated that resident would refuse to shower and staff would encourage resident to shower. R3 stated would need assistance with shower. End of shift report shows that either showers were given to R3 or refusal was documented in July and early August of 2021. Narrative charting revealed that R3 was cleaned up or showered after accidents.

Residents room has feces on the carpet
Interview with resident revealed that there was feces on the carpet before. Interview with staff indicated that feces were cleaned. On 8/12/2021, LPA did not observe R3's room carpet had feces.

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

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210802081302
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: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation.
The facility shall be clean, safe, sanitary and in good repair at all times....
This requirement is not met as evidence by:
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Executive Director (ED) has agreed to conduct training for housekeeping staff regarding cleaning all resident's room and to document resident refusals. ED will submit training log and materials to
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Based on investigation, licensee did not comply with the section cited above by not cleaning R3's room which poses a potential health and safety risk to the persons in care.
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CCLD by POC date.
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4