079200575-1-6-2023-15-AS-KHOS-CN6PCV-20230117101235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 01/06/2023
Date Signed: 01/06/2023 04:33:52 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
03/04/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210304145418

FACILITY NAME:	COMMONS AT DALLAS RANCH, THE		FACILITY NUMBER:	079200575
ADMINISTRATOR:	ANDREWS, BRITANNY		FACILITY TYPE:	740
ADDRESS:	4751 DALLAS RANCH ROAD		TELEPHONE:	(925) 754-7772
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	123	CENSUS: 89	DATE:	01/06/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Diane Taylor, Director of Health and Services		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident sustained multiple falls resulting in injuries
Staff are mismanaging residents medication
Staff are not treating residents equally

INVESTIGATION FINDINGS:

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On 01/06/2023 at 10:10AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. LPA met with Director of Health Services, Diane Taylor.

During the investigation, LPA reviewed documents such as but not limited to, incident reports, medication administration records (MAR), R1’ care plan, physician’s report and facility’s narrative charting for R1. LPA could not interview R1 since she no longer lives at the facility. LPA conducted interview with facility residents.

Continues on LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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-20210304145418

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: 01/06/2023

NARRATIVE

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Allegation: Resident sustained multiple falls resulting in injuries

Based on records review, it was revealed that on 12/21/2020 R1 was found on the bathroom shower floor, staff called 9-1-1 but resident refused to go to the hospital. Staff called R1’s family and informed the incident. Based on records review, R1 had bruises from the fall incident on 12/21/2021, however R1’s care plan stated that R1 is independent in toileting needs and staff was advised to just monitor and notify supervisor if any evidence of odor or toileting needs.

Allegation: Staff are mismanaging residents’ medication

Based on records review, medication administration records (MAR) revealed that staff gave R1’s medication according to physician’s order. R1’s MAR revealed there was no miss medications and discontinued medication was stopped per doctor’s order.

Allegation: Staff are not treating residents equally

During the course of investigation, LPA interviewed staff and residents. Based on residents’ interview, they denied any unequal treatment from staff. Staff stated that all residents are treated equally according to each residents needs since each residents have unique needs.

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

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC9099 (FAS) - (06/04)

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