079200575-8-7-2024-15-AS-KHOS-D84QHR-20240813121136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 08/07/2024
Date Signed: 08/07/2024 04:57:51 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
07/30/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240730142411

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:	03:55 PM
MET WITH:	Brittany Karlinski, Executive Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff did not keep the facility free from bedbugs
Staff did not keep the facility free of pest

INVESTIGATION FINDINGS:

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On 08/07/24 at 3:55PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, gathered information and delivered investigation findings to executive director (ED). LPA explained the purpose of the visit with ED.

During investigation, the department interviewed staff and obtained the following documents from ED – personnel record, residents’ roster, communications to residents and responsible parties with regards to bed bug infestation, exterminator reports and scheduled treatments, incident reports.

Continued on next page, LIC 9099-C

Substantiated

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-20240730142411

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: Staff did not keep the facility free from bedbugs
Investigation Finding: Substantiated
During investigation, LPA interviewed staff (ED) who confirmed that there was a bed bug infestation in one of the resident's apartment in assisted living on 11/14/23. Staff relocated R1 and R2 into a temporary apartment with a new mattress while their apartment was fumigated and treated. ED stated that when R1 moved to the memory care unit on 01/04/24, bed bug re-infestation was found in his recliner and wheelchair on 01/07/24. ED stated that a few apartments have been identified as needing treatment due to re-infestation and fumigation has been scheduled with an exterminator company to resolve the issue. Review of written notice of bed bug treatments dated 08/02/24 confirmed the presence of bed bugs at the facility. ED stated that to ensure the effectiveness of the treatment, all residents' beddings and clothes will be hot-water washed and residents temporarily relocated for a few hours while fumigation was completed. 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 did not keep the facility free from bed bugs was found to be substantiated.

Allegation: Staff did not keep the facility free of pest
Investigation Finding: Substantiated
During investigation, LPA interviewed staff (ED, S1) who stated that one resident loves to throw bird seed outside the memory care area close to the open field. Staff confirmed with LPA that 2 mice were observed in the kitchen and one resident's memory care bedroom area. 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 did not keep the facility free of pest was found to be substantiated.

Deficiencies are 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.

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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Control Number 15-AS-20240730142411

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: 08/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/07/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Deficiency cleared during visit. On 08/07/24, ED submitted to LPA a written beg bug treatment schedule with exterminator company to resolve re-infestation issue in memory care
	8 9 10 11 12 13 14	This requirement was not met as evidenced by bed bug infestation in memory care which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	dated 08/05/24.
Type B 08/07/2024 Section Cited CCR 87303(d)(3)	1 2 3 4 5 6 7	All persons shall be protected against hazards within the facility. This requirement was not met as evidenced by presence of pest in the	1 2 3 4 5 6 7	Deficiency cleared during visit. LPA confirmed with staff (ED, S1) that the mice infestation was resolved by plugging the holes in the memory care kitchen and resident's unit on
	8 9 10 11 12 13 14	memory care areas which posed a potential health & safety risk to residents in care	8 9 10 11 12 13 14	July 30, 2024.

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

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