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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 02:37:52 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
09/09/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220909101157
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:
02:15 PM
MET WITH:Brittany Karlinski, Administrator/Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff overmedicated resident
Staff did not follow doctor’s orders
INVESTIGATION FINDINGS:
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On 10/25/23 at 2:15PM, 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-20220909101157
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 overmedicated resident
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of incident report dated 08/01/22 showed R1’s medications were not being administered as prescribed from 02/23/22 until 05/13/22. A signed and dated medication list from R1’s primary care physician (PCP) indicated R1 should only be taking 2 medications. 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 overmedicated resident was found to be substantiated.

Allegation: Staff did not follow doctor’s orders
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED) who confirmed that medication errors occurred due to staff failing to contact R1’s authorized representative (POA) and primary care physician (PCP) in clarifying a change in the medication administration records which were accepted without proper verification of physician’s orders. 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 follow doctor’s orders 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-20220909101157
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)(3)
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A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response..
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Deficiency corrected during visit. Administrator completed in-service retraining of all staff on medication administration 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(d)(1)
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Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication.
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Deficiency corrected during visit. Administrator completed in-service retraining of all staff on incidental medical care 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
09/09/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220909101157

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:
02:15 PM
MET WITH:Brittany Karlinski, Administrator/Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not safeguard resident’s property
Staff did not notify resident’s POA of change in resident’s condition
Staff did not notify POA of incidents
Staff did not respond to POA
Staff did not ensure resident’s hygiene care was met
INVESTIGATION FINDINGS:
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On 10/25/23 at 2:15PM, 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-20220909101157
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 did not safeguard resident’s property
Investigation Finding: Unsubstantiated
During investigation, the department reviewed R1’s signed admission agreement dated 01/22/20 which showed that the facility is not responsible for the loss or theft of valuables from a resident’s apartment. Review of authorized representative’s (POA) letter with facility staff dated 08/31/22 showed she reduced the monthly bill for the lost bedding she replaced in June 2022. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not safeguard resident’s property 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 staff did not safeguard resident’s property is unsubstantiated.

Allegation: Staff did not notify resident’s POA of change in resident’s condition
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s incident reports dated 03/08/22 and 07/09/22 showed staff notified R1’s authorized representative (POA) and primary care physician (PCP) of incidents involving R1 being unresponsive and sent to the hospital due to a change in condition. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not notify resident’s POA of change in resident’s condition 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 staff did not notify resident’s POA of change in resident’s condition 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-20220909101157
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 did not notify POA of incidents
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s incident reports from 03/04/2020 until 08/01/22 showed staff notified R1’s family and primary care physician of incidents involving aggressive behaviors towards other residents and staff, unwitnessed fall, 911/ER visits, change in condition and medication errors. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not notify POA of incidents 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 staff did not notify POA of incidents is unsubstantiated.

Allegation: Staff did not respond to POA
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED, S1) who stated that they communicated with resident’s (R1) authorized representative (POA) frequently regarding R1’s level of care, billing, new and discontinued medications orders. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not respond to POA 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 staff did not respond to POA 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-20220909101157
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 did not ensure resident’s hygiene care was met
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s needs and services records showed staff provided total assistance for R1’s hygiene care, grooming, dressing, toileting, ambulation and transfers. LPA interviewed staff who stated R1 would constantly refuse showers so they would give her a sponge bath instead upon refusal. Review of Incident report dated 06/29/22 showed staff was hit on the head by R1 while assisting her with a shower. Staff called for help because R1 started to swing at her again. Another staff took over and was able to complete R1’s dressing. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure resident’s hygiene care was met 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 staff did not ensure resident’s hygiene care was met 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