079200575-2-15-2024-15-AS-BFOG-D2VUWT-20240228145717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:11:50 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
03/24/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230324115547

FACILITY NAME:	COMMONS AT DALLAS RANCH, THE		FACILITY NUMBER:	079200575
ADMINISTRATOR:	BRITTANY KARLINSKI		FACILITY TYPE:	740
ADDRESS:	4751 DALLAS RANCH ROAD		TELEPHONE:	(925) 754-7772
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	123	CENSUS: 86	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Brittany Karlinski, Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Questionable death
Staff do not dispense medication to residents in a timely manner

INVESTIGATION FINDINGS:

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On 02/15/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegation. LPA explained the purpose of the visit with ADM.

During investigation, the Department obtained the following documents from the facility – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, Physicians orders, narrative charting, medication worksheets, death report.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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-20230324115547

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: 02/15/2024

NARRATIVE

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Allegation: Questionable death
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s medical documents showed that on 12/06/22, R1’s doctor received a fax from facility staff (S1) who notified him about R1’s cough and congestion. Staff requested for cough syrup and an appointment with the doctor. Lab tests were ordered and a chest x-ray was performed on 12/06/22. The results of the chest x-ray showed R1’s lungs were clear and the pleura unremarkable. On 12/06/22, staff (S2) also notified the doctor when R1 developed a fever and staff gave R1 Tylenol which reduced her fever to normal. Staff continued to monitor R1 and on 12/07/22 at approximately 0500 hours, R1 passed away. Documents obtained do not suggest R1’s death was a result of neglect or lack of care for suspicious circumstances from facility staff. Review of death report showed immediate cause of death was acute hypoxic respiratory failure.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of questionable death 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 of questionable death is unsubstantiated.

Continued on next page, LIC 9099-C1

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230324115547

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: 02/15/2024

NARRATIVE

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Allegation: Staff do not dispense medication to resident in a timely manner
Investigation Finding: Unsubstantiated
Review of R1’s centrally stored medication logs and medication administration records dated 06/27/22 showed that staff totally assisted R1 with prescribed medications daily. Staff documented medications, central storage and assistance with residents in their electronic database which recorded daily intake of prescribed medications by residents, reports to doctors of any resident medication refusal or any missed dosages and any changes to residents’ physicians’ orders. Prior interviews conducted by LPA on 03/08/23 with staff (S1) and residents (R2, R3) confirmed that staff gave total assistance with daily prescribed medications and dispensed medications to residents in a timely manner.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff do not dispense medication to resident in a timely manner 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 do not dispense medication to resident in a timely manner is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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