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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:48:10 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
01/14/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210114163516
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: 83DATE:
02/17/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Britanny Andrews, Executive DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff did not assist residents with hygiene needs
Facility staff did not ensure resident had clean clothing
Resident was left in soiled clothing for an extended period of time
INVESTIGATION FINDINGS:
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On 02/17/23 at 1:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with executive director (ED) to deliver the findings of above allegations. LPA explained the purpose of the visit with ED.

Allegation: Staff did not assist residents with hygiene needs
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, former ED acknowledged with LPA during visit that residents, authorized representatives and staff expressed concerns regarding residents not being changed in a timely manner, not getting food or at all, getting residents up late, not receiving their scheduled showers and not getting medications on time due to insufficient staffing. The preponderance of evidence has been met. Therefore, this allegation is substantiated.
Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
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 6
Control Number 15-AS-20210114163516
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: 02/17/2023
NARRATIVE
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Allegation: Staff did not ensure resident had clean clothing
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, former ED confirmed with LPA during visit that residents are not being assisted in a timely manner, resulting in medication, feedings, showers, diaper changes and ADL being done late or not at all due to insufficient staffing. These concerns/ statements were communicated by staff, residents and residents’ family members. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Resident was left in soiled clothing for an extended period of time


Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews which were conducted, former ED acknowledged with LPA during visit that staff response time was an ongoing problem resulting in residents not being changed in a timely manner or not at all, getting residents up late, not receiving their scheduled showers and not getting their medications on time. ED reported having difficulty hiring staff because of limited applicants. The preponderance of evidence has been met. Therefore, this allegation 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.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20210114163516
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: 02/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited
CCR
87705(c)(4)
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(4) “There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.”
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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.
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This requirement was not met as evidenced by staff failing to assist residents hygiene needs which posed a potential health & safety risk to residents in care.
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In-service staff retraining on residents’ care and supervision were conducted in August and September 2022.
Type B
02/17/2023
Section Cited
CCR
87468.2(a)(1)
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To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance…”
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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.
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14
This requirement was not met as evidenced by staff did not ensure resident had clean clothing which posed a potential health & safety risk to resident in care
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In-service staff retraining on residents’ care and supervision were 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20210114163516
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: 02/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited
CCR
87468.2(a)(4)
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2
3
4
5
6
7
To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.”
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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 resident left in soiled clothing for an extended period of time which posed a potential health & safety risk to resident in care
8
9
10
11
12
13
14
In-service staff retraining on residents’ care and supervision were conducted in August and September 2022.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/14/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210114163516

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: 83DATE:
02/17/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Britanny Andrews, Executive DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not dispense medication as prescribed
Staff is not responding to resident’s authorized representative in a timely manner
Facility is not kept clean
Staff did not provide a safe environment
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/17/23 at 1:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with executive director (ED) to deliver the findings of above allegations. LPA explained the purpose of the visit with ED.

Allegation: Staff did not dispense medication as prescribed
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, review of resident’s (R1) medication records show medications were administered by staff as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20210114163516
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: 02/17/2023
NARRATIVE
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3
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Allegation: Staff is not responding to resident’s authorized representative in a timely manner
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews which were conducted, former ED and Director of Memory Care confirmed with LPA during visit that they have discussed R1’s issues with authorized representative on numerous occasions and denied not responding to her in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Allegation: Facility is not kept clean


Investigation Finding: UNSUBSTANTIATED
During investigation, LPA toured the facility with administrator including but not limited to the memory care and assisted living units, bathrooms, kitchen, dining, reception areas and outside patio. LPA observed facility to be in good repair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated

Allegation: Staff did not provide a safe environment


Investigation Finding: UNSUBSTANTIATED
LPA conducted a health & safety check on 02/10/21 and toured the facility with the administrator, including but not limited to bedrooms, kitchen, bathrooms and common areas. Residents in care appear to be safe and there were no imminent health or safety concerns during visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated

Exit Interview conducted and a copy of this report provided to ED.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6