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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 01/15/2025
Date Signed: 01/15/2025 04:26:46 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
01/08/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250108082539
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: 89DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Diane Taylor, Director of Health Services
Angela Caldera, Memory Care Director		TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff left resident on floor for an extended period of time
INVESTIGATION FINDINGS:
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On 01/15/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with Director of Health Services (DHS), gathered information relevant to the allegations and delivered investigation findings to DHS. LPA explained the purpose of the visit with DHS.

During investigation, LPA obtained the following documents from DHS: Memory care resident roster (November 2024), Staff roster (LIC 500), R1's admission agreement, Needs & Services Plan, Assessment report, Physician's report, incident report.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
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 5
Control Number 15-AS-20250108082539
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: 01/15/2025
NARRATIVE
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Allegation: Staff left resident on floor for an extended period of time
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. Review of R1’s admission agreement showed he was first admitted at the facility on 11/25/24 in the Memory Care unit with a primary diagnosis of dementia. Responsible party (POA) stated that on 11/29/24 at approximately 11:30PM, she received a couple of voice messages from staff (S1) advising her that R1 had an unwitnessed fall in his room at around 10:30PM, was confused & lethargic and had blood on his left elbow. Review of hospital discharge summary report dated 11/30/24 to 12/07/24 showed R1’s was admitted for altered mental status due to dementia precipitated by dehydration rhabdomyolysis (muscle weakness due to a fall & can’t get up for an extended period of time). POA stated that R1 goes to bed at around 8PM daily. Review of incident report dated 11/29/24 showed R1 had an unwitnessed fall on 11/29/24 at around 10:30PM when the night shift staff conducted their status check rounds in the memory care unit. 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 left resident on floor for an extended period of time was found to be substantiated.

Deficiency is 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/08/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250108082539

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: 28DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Diane Taylor, Director of Health Services
Angela Caldera, Memory Care Director		TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not ensure resident was hydrated resulting in dehydration.
Staff did not communicate with resident's responsible party
INVESTIGATION FINDINGS:
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On 01/15/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with Director of Health Services (DHS), gathered information relevant to the allegations and delivered investigation findings to DHS. LPA explained the purpose of the visit with DHS.

During investigation, LPA obtained the following documents from DHS: Memory care resident roster (November 2024), Staff roster (LIC 500), R1's admission agreement, Needs & Services Plan, Assessment report, Physician's report, incident report.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20250108082539
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: 01/15/2025
NARRATIVE
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Allegation: Staff did not ensure resident was hydrated resulting in dehydration
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible party and reviewed resident (R1) documents. LPA interviewed staff (S2, S3) who stated that R1 was independent with his daily meals and was observed to eat and drink water & juice during mealtimes (3X per day) and offered drinks with snacks at 10AM and 2:30PM daily. They stated they offered him drinks frequently but sometimes he refused since he did not feel thirsty. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure resident was hydrated resulting in dehydration 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 was hydrated resulting in dehydration is unsubstantiated.


Allegation: Staff did not communicate with resident’s responsible party
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (S2) who stated that they communicated with R1’s responsible party (POA) regarding R1’s behaviors (being quiet, wandering with coat under arm wanting to go home, un-witnessed fall and ER hospital visit on 11/29/24. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not communicate with resident’s responsible party 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 communicate with resident’s responsible party is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250108082539
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: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/23/2025
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
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By POC due date, DHS agrees to submit to CCL completed staff in-service retraining on proper care and supervison of residents in compliance with Title 22 Section 87466 regulations.
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This requirement was not met as evidenced by staff left resident on floor for an extended period of time 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5