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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200575
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:14:01 PM


Document Has Been Signed on 08/01/2024 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 103DATE:
08/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Brittany Karlinski, Executive DirectorTIME COMPLETED:
01:00 PM
NARRATIVE
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On 08/01/2024 at 11:15 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/14/2024. LPA met with Executive Director (ED), Brittany Karlinski and explained the purpose of the visit.

The incident report received stated that Resident (R1) eloped from the side exit door of the memory care unit at around 8:15 AM on 06/14/2024. The incident report indicate that another Resident (R2) observed R1 walking out the back door and that the staff located R1 outside across the street.

LPA interviewed Staff (S1) that stated there were 3 (three) memory care caregivers and 1 (one) Med Tech scheduled during that time. S1 stated that R1 exit the side door which is located on the east side of the facility building. S1 stated that the alarms went off when the door was breached and that R2 went to staff to inform. S1 stated that the caregivers were on the opposite side of the area where R1 eloped and were currently occupied with breakfast and other tasks with other residents in memory care. S1 stated that after R2 informed the staff, the staff immediately went outside and found R1 standing outside across the street. S1 stated that staff brought R1 back to the facility and that R1's responsible party was notified. S1 stated they had a care meeting with the family and suggested that R1 be placed on a 1:1 assistant. S1 stated that R1 was placed on a 1:1 assist on 06/14/2024 from 7AM to 7PM daily.


LIC809-C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: COMMONS AT DALLAS RANCH, THE
FACILITY NUMBER: 079200575
VISIT DATE: 08/01/2024
NARRATIVE
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LIC809-C Continued....

LPA obtained a copy of resident's (R1) Physician's Report, Staff Schedule for 06/14/2024, Staff Schedule (06/10/24, 06/16/24), R1's Preplacement Appraisal (03/28/24), Resident Assessment (05/26/24, 06/28/24), Needs and Services Plans (05/31/24, 07/08/24), Physician's Orders (08/01/24), Service Plan (07/09/24), Health and Safety Assessment (07/09/24) and copies of Wander Management System and Elopements (12/01/23) policies.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report was provided to ED.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/01/2024 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2024
Section Cited
CCR
87468.2(a)(4)

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To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency...

This requirement was not met as evidence by:
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Administrator submitted copies to CCLD of In-Service training meetings that address Delayed Egress, Elopement Drill, WanderGuard Alarms,
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Based on interview and record review, the licensee did not comply with the section cited above by staff not responding timely before R1 eloped outside the building and across the streets which posed a potential health and safety risk to persons in care.
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Elopement Policy and Elopement Drills (All Shifts) which were conducted on 06/06/24, 06/18/24, 06/19/24, 06/22/24, 06/23/24 and 07/31/24. Deficiency cleared during visit.

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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) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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