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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 10/25/2023
Date Signed: 10/25/2023 02:11:16 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
06/15/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220615132430
FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:BRITTANY KARLINSKIFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 96DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Brittany Karlinski, Administrator/Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff mismanaged resident’s medication
Staff did not order refills in a timely manner
INVESTIGATION FINDINGS:
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On 10/25/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, physicians’ orders, medication administration records, narrative charting notes, incident reports.

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: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
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 7
Control Number 15-AS-20220615132430
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: 10/25/2023
NARRATIVE
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Allegation: Staff mismanaged resident’s medication
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s incident report dated 04/25/22 showed missed administration of R1’s prescribed medications from 03/17/22 until 04/28/22 by facility staff. 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 mismanaged resident’s medication was found to be substantiated.

Allegation: Staff did not order refills in a timely manner
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s medical records showed that staff did not order timely refills of R1’s medications due to mismanagement of prescribed medications from 03/17/22 until 04/28/22. 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 did not order refills in a timely manner 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.

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

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20220615132430
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: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2023
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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Deficiency corrected during visit.
Administrator completed in-service retraining of all staff on medication administration in August 2022 in compliance with Title 22 Section 87465 regulations.
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This requirement was not met as evidenced by staff mismanaging resident’s medication which posed a potential health & safety risk to residents in care.
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Type B
10/25/2023
Section Cited
CCR
87465(h)(3)
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Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills.
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Deficiency corrected during visit. Administrator completed in-service retraining of all staff on medication refills in August 2022 in compliance with Title 22 Section 87465 regulations.
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This requirement was not met as evidenced by staff not timely ordering medication refills 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
06/15/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220615132430

FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:BRITTANY KARLINSKIFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 96DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Brittany Karlinski, Administrator/Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident lost severe weight while in care
Resident sustained a fall while in care
Resident sustained UTI’s while in care
Resident was dehydrated while in care
Insufficient staffing to meet residents’ needs
INVESTIGATION FINDINGS:
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On 10/25/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, physicians’ orders, medication administration records, narrative charting notes, incident reports.

Continued on next page, LIC 9099-C pg2
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: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20220615132430
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: 10/25/2023
NARRATIVE
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Allegation: Resident lost severe weight while in care
Investigation Finding: Unsubstantiated
During investigation, the department reviewed resident’s admission agreement which showed resident (R1) was first admitted at the facility under hospice care on 01/28/22. Hospice records showed R1 was on a regular diet and able to feed herself with minimal assistance from staff. Review of hospital discharge report dated 02/24/22 showed R1’s weight at 124 lbs. with a diagnosis of Alzheimer’s dementia with sundowning behaviors. New medications were ordered. On 02/16/22, R1’ s primary care physician (PCP) ordered a new prescription of Senna for R1’s constipation. On 03/14/22, R1’s PCP also prescribed Ensure nutritional shakes to be taken twice a day if she does not finish her meals. On 04/05/22, staff (S1) notified R1’ s primary care physician (PCP) that R1’s weight was at 126 lbs the last week of March and now weighed 116 lbs. Staff sent R1 to the hospital for treatment and evaluation of weight loss. Lab work was completed on 04/18/22 and on 4/19/22, R1’s PCP ordered staff to discontinue senna medication and continue calcium supplements. Staff stated that despite their efforts in encouraging R1 to eat and take her nutritional shakes, she continued to lose weight. R1 weighed 109 lbs when she left the facility on 06/13/22. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident lost severe weight while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that 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 resident lost severe weight while in care is unsubstantiated.

Continued on next page, LIC 9099-C pg3
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20220615132430
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: 10/25/2023
NARRATIVE
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Allegation: Resident sustained a fall while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s narrative charting showed she had an unwitnessed fall on 05/25/22. Staff assessed R1, called 911, sent her to the hospital for evaluation & treatment and notified authorized representative (POA)/ primary care physician (PCP) of the incident on 05/25/22. R1 was treated and returned back to the facility the same day with new medication orders. LPA observed staff assisted R1 in timely getting medical treatment and monitored R1 while in care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident sustained a fall while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that 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 resident sustained a fall while in care is unsubstantiated.

Allegation: Resident sustained UTI’s while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of hospital discharge record dated 02/28/22 showed R1 was diagnosed with acute UTI along with dementia with behavioral disturbance and hospital issued new medications for treatment. Staff administered R1’s antibiotics for 7 days until her UTI was cleared. LPA observed no other episodes of UTI were reported during her stay at the facility. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident sustained UTI’s while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that 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 resident sustained UTI’s while in care is unsubstantiated.

Continued on next page, LIC 9099-C pg4
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20220615132430
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: 10/25/2023
NARRATIVE
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Allegation: Resident was dehydrated while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s physician’s orders dated 03/14/22 and 04/20/22, showed prescribed Ensure Liquid Vanilla shakes were ordered for R1 to take twice daily as needed if R1 does not finish her lunch and dinner meals. Staff stated that despite their efforts in encouraging R1 to eat and take her nutritional shakes, she continued to lose weight. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident was dehydrated while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that 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 resident was dehydrated while in care is unsubstantiated.

Allegation: Insufficient staffing to meet residents’ needs
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of personnel records showed the facility had sufficient staffing including third party agency staff available on scheduled AM, PM and NOC shifts to provide care and supervision to residents in care. LPA interviewed residents (R2, R3) who stated that staff met their needs. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that there is insufficient staffing to meet residents’ needs and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that 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 there is insufficient staffing to meet residents’ needs is unsubstantiated

Exit interview conducted 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: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7