079200575-2-15-2024-15-AS-BFOG-D2VUVA-20240228145447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:10:18 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
03/08/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230308161607

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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Multiple residents fell due to staff neglect
Staff are not isolating COVID-19 residents
Staff are not providing adequate food service to residents
Staff are not using proper sanitizing methods
Staff are not responding to residents call buttons in a timely manner
Staff are not cleaning residents rooms

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 agreements, physicians reports, needs & services plans, Physicians orders, COVID infection control plan, COVID Contra Costa Public Health (CDPH guidance) records, staffing agency records/work schedules, housekeeping schedules, call logs, meal schedules.

Continued on next page, LIC-9099C

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-20230308161607

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: Multiple residents fell due to staff neglect
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Staff (S1) stated resident (R1) is checked 4 times per shift since she is identified as a fall risk. She requires 1 person total assist in bathing (2X per week), total assist in dressing, preparation of grooming items, toileting, wheelchair escort to and from activities, meals, transfers, medication assist and is a fall risk, Her care is a level 5. Review of R1's incident reports submitted to CCL dated 11/16/22 (8:15PM), 12/31/22 (12AM), 02/19/23 (6PM) and 02/28/23 (7PM) show R1 had several un-witnessed falls. R1 told staff that she was trying to get up and slid down from the bed. Med tech checked R1 and no injury was observed. R1 denied pain. Med tech and 3 care staff helped her get up and lay her down the bed. Staff notified authorized representative and primary care physician. Review of R2's incident reports submitted to CCL dated 11/28/22 (3AM), 12/03/22 (8PM), 12/24/22 (2AM) show R2 had several un-witnessed falls. While doing rounds and safety checks, med tech and care staff found R2 on the hallway floor close to his room. R2 stated he was walking using his walker and lost his balance and fell. Med tech and care staff checked R2 for injury. R2 stated he did not hit his head. Staff called 911 and R2 was sent to the hospital for evaluation and treatment. Staff also notified authorized representative and primary care physician (PCP). R2 came back to the facility with no new orders or diagnosis. A PCP follow-up video call was done on 12/29/22.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of multiple residents fell due to staff neglect 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 multiple residents fell due to staff neglect 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)

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Control Number 15-AS-20230308161607

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 are not isolating COVID-19 residents
Investigation Finding: Unsubstantiated
During investigation, LPA observed positive residents quarantined and separated from negative residents during prior unannounced visits on 12/19/22 and 02/17/23. LPA also observed staff temporarily suspending all communal activities and meals in accordance with Public Health guidelines on infection control. Review of staff COVID statements letters showed staff followed Public Health infection control guidelines in implementing quarantine requirements until released from COVID -19 surveillance by Public Health,

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not isolating COVID-19 residents 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 are not isolating COVID-19 residents is unsubstantiated.

Allegation: Staff are not providing adequate food service to residents
Investigation Finding: Unsubstantiated
During investigation, LPA confirmed with residents (R2, R3) that they are provided 3 meals plus snacks and drinks by staff who stated that residents’ meals (breakfast, lunch, dinner, snacks, drinks) were delivered daily during COVID outbreaks when communal dining and activities were temporarily suspended. Staff confirmed with LPA that they followed COVID-19 Public Health guidelines wherein meal trays or boxed lunches were delivered to assisted living residents’ apartments during mealtimes and in between snacks.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff are not providing adequate food service to residents 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 are not providing adequate food service to residents is unsubstantiated. Continued on next page, LIC 9099-C2

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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Control Number 15-AS-20230308161607

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 are not using proper sanitizing methods
Investigation Finding: Unsubstantiated
During investigation. LPA observed staff cleaning and disinfecting tables, chairs, floors, bathrooms, reception areas during unannounced visits on 12/19/22 and 02/17/23. LPA observed the facility to be clean, in good repair and well ventilated. LPA observed a universal screening station at the front desk where visitors, staff and residents are routinely checked for COVID-19 symptoms. Hand sanitizers, face masks, gloves were observed available at the front desk.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff are not using proper sanitizing methods 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 are not using proper sanitizing methods is unsubstantiated.

Allegation: Staff are not responding to residents’ call buttons in a timely manner
Investigation Finding: Unsubstantiated
During investigation, LPA confirmed with residents (R2, R3) that staff responded timely to call buttons when activated. ADM stated staff are required to respond to call lights within 15 minutes and failure to do so will result in an investigation and potential disciplinary action. Review of staff in-service meeting notes dated 11/11/22 and 12/16/22 required staff to respond to residents’ call button within 15 minutes with med techs as back-up.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff are not responding to residents’ call button 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 are not responding to residents’ call buttons in a timely manner is unsubstantiated. Continued on next page, LIC 9099-C3

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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Control Number 15-AS-20230308161607

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 are not cleaning residents’ rooms
Investigation Finding: Unsubstantiated
During investigation, LPA conducted an unannounced health & safety check on 03/30/23 at 12:55PM and observed random residents’ rooms (105V, 104V, 113V) to be clean, odor free and in good repair. Prior unannounced visits on 12/19/22 and 02/17/23 showed residents’ rooms to be clean and in good repair. Review of facility’s housekeeping schedules from 11/2022 until 03/30/2023 showed sufficient housekeeping staff ( 5 housekeepers and 2 maintenance staff) performing housekeeping chores daily.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not cleaning residents’ rooms 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 are not cleaning residents’ rooms 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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