079200575-8-15-2024-15-AS-KHOS-D8HH75-20240826055608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:01:41 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
08/07/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240807144128

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: 109	DATE:	08/15/2024
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Brittany Karlinski, Executive Director/Administrator (ED/ADM)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not providing adequate housekeeping services to residents
Staff are not ensuring residents are provided with toiletries

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/15/24 at 2:25PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit and met with administrator (ADM) to deliver the findings 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 agreements, housekeeping records.

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: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 2

Control Number 15-AS-20240807144128

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: 08/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff are not providing adequate housekeeping services to residents
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of staff, reviewed housekeeping schedules and toured the memory care unit with executive director (ED). LPA inspected random toilets in the memory care unit and observed toilets in good repair, clean, free of mold and did not have urine/feces odors. Review of housekeeping schedules for 07/29/24 until 09/01/24 showed memory care unit cleaned daily by housekeeping staff. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not providing adequate housekeeping services 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 housekeeping services to residents is unsubstantiated.

Allegation: Staff are not ensuring residents are provided toiletries
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of staff and reviewed random residents’ (R1, R2, R3, R4) admission agreements. Executive Director (ED) stated residents are responsible for their own toiletries and incontinent supplies. Review of random residents (R1, R2, R3, R4) admission agreements showed facility is not responsible for furnishing or paying for any health care items or services not expressly included in the admission agreement such as medical supplies and incontinence products. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff are not ensuring residents are provided toiletries 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 ensuring residents are provided toiletries is unsubstantiated.

No deficiencies cited on this complaint. 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: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2