079200575-8-7-2024-15-AS-KHOS-D84QDN-20240813120500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:58:07 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
02/23/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240223165313

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: 105	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Brittany Karlinski, Executive Director		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Facility illegally evicted a resident in care
Facility did not ensure that resident's call system was operable

INVESTIGATION FINDINGS:

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On 08/07/24 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, call logs, communication records regarding resident’s (R1) inappropriate behaviors towards staff, eviction notice, conference meeting logs with responsible party, incident reports.

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: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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-20240223165313

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: 08/07/2024

NARRATIVE

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Allegation: Facility illegally evicted a resident in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of staff and reviewed R1’s signed admission agreement dated 08/18/20 which showed that the facility manager (ED) may terminate the signed agreement at any time upon thirty days written notice to the resident (R1). A written 30-day eviction notice was delivered to R1 on 02/06/24 by ED due to R1's failure to comply with the general policies of the community after multiple verbal & written warnings and conference meetings were held by ED with R1 and responsible party to resolve the inappropriate behaviors displayed by R1 towards staff from 03/2022 until 01/2024. 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 facility illegally evicted a resident in care is unsubstantiated.

Allegation: Facility did not ensure that resident’s call system was operable
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of staff and reviewed resident’s (R1) call logs and incident reports. Executive Director (ED) stated that R1 had an un-witnessed fall early AM in his bathroom on 05/04/23. ED stated that R1's call pendant was not working that day and immediately had maintenance repair the call pendant the same day. Review of R1’s incident report dated 05/04/23 showed staff notified R1’s authorized representative (POA) and primary care physician (PCP) of incident involving R1's un-witnessed fall in independent living and that R1 was sent to the hospital for evaluation on 05/04/23. R1’s call logs dated 05/04/23 showed staff checked and cleared R1's activated call pendant at 9AM and 3PM. ED stated monthly checks are conducted on all residents' call pendants to ensure that they are operable. 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 facility did not ensure that resident’s call system was operable is unsubstantiated.

No deficiencies cited on this date. 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: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

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