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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 09/05/2024
Date Signed: 09/20/2024 02:46:54 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
05/16/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230516162748
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: 109DATE:
09/05/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Brittany Karlinski, Administrator (ADM) / Executive Director
Roezi Vermouth, Director of Wellness (MOD)		TIME COMPLETED:
04:50 PM
ALLEGATION(S):
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9
Facility did not have sufficient staff to meet the needs of the residents in care
Resident sustained multiple unwitnessed falls resulting in injury
Facility staff did not assist resident with activities of daily living in a timely manner
INVESTIGATION FINDINGS:
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On 09/20/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with manager on duty (MOD) to amend and re-deliver investigation findings of above allegations. LPA explained the purpose of the visit with MOD.

During investigation, the department obtained the following documents from administrator – Resident roster with contact information, Personnel record (LIC500), pre-placement appraisal, admission agreements, needs & services plans, physician’s reports, Doctors’ orders, Activities of daily living schedules (ADLs), reappraisals, incident reports, notifications to authorized representative(s) / physicians of change in condition, Level of Care Notes, Hospital discharge reports.
Continued on next page LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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 8
Control Number 15-AS-20230516162748
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: 09/05/2024
NARRATIVE
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Allegation: Facility did not have sufficient staff to meet the needs of the residents in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff and residents. Staff (S1) stated although they were short staffed during this period, residents were given their medications, feedings, showers, diaper changes and activities of daily living (ADLs) daily. LPA interviewed other residents (R2, R3) at the facility. R2 stated that both himself and R3 reside in the same apartment at the facility for over 2 years and that R3 is totally dependent and requires total care. R2 stated that the response times of the caregivers were sometimes delayed due to short staffing. However, the staff did a good job in delivering meals, giving weekly showers, diaper changes and following COVID-19 safety protocols. He stated that both him and his wide did not contract COVID-19 while at the facility. Although the allegation that facility did no have sufficient staff to meet the needs of the residents in care may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated.

Allegation: Resident sustained multiple unwitnessed falls resulting in injury.
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s admission agreement showed he was first admitted at the facility on 01/21/2020. R1’s Incident reports dated 03/25/20, 04/01/20, 04/29/20, 08/26/20 and 10/28/20 showed that staff reported R1 had unwitnessed falls in his bedroom and bathroom. On each of these incidents, staff assessed R1 for injuries and when no injuries were found, staff assisted him back to his bed and continued to monitor him. Staff notified his responsible party (POA) and his primary physician (PCP) of each incident. On 11/17/20 at 06:42 AM, staff found R1 on the floor next to his bed. Staff immediately called 911 because they observed R1 grabbing the back right side of his head and notified his responsible party (POA) and primary care physician (PCP). Paramedics took him to the hospital for evaluation and treatment. R1 underwent surgery to reduce the bleed on his brain. R1 was transferred to a skilled nursing facility after discharge from the hospital and did not return to the facility. Although the allegation that resident sustained multiple unwitnessed falls resulting in injury may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated.
Continued on next page, LIC 9099-C1
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 15-AS-20230516162748
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: 09/05/2024
NARRATIVE
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Allegation: Facility staff did not assist resident with activities of daily living in a timely manner.
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Staff (S1) stated resident (R1) required a 1 person total assist in bathing (2X per week) and total medication assist. He also required standby assist with transfers and minimal assist with prompting, cueing & reminding, independent with toileting, preparation of grooming items, ambulated independently with a walker to and from activities, meals and was a fall risk. R1’s level of care was a Level 3. Review of R1's incident reports submitted to CCL by staff dated 03/25/20, 04/01/20, 04/29/20, 08/26/20, 10/28/20 show R1 had several un-witnessed falls. R1 told staff that he was trying to get up and slid down from the bed while going to the bathroom. Med tech checked R1 and no injury was observed. R1 denied pain. Med tech and care staff helped him get up and lay him down the bed. Staff notified authorized representative and primary care physician of each incident. On 11/17/20 at 06:42 AM, staff found R1 on the floor next to his bed. Staff immediately called 911 because they observed R1 grabbing the back right side of his head and notified his responsible party (POA) and primary care physician (PCP). R1 was sent to the hospital for evaluation and treatment. Although the allegation that facility staff did not assist resident with activities of daily living in a timely manner may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated.

No deficiencies cited during visit.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 15-AS-20230516162748
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: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited
CCR
87411(a)
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Complaint investigation finding was amended to unsubstantiated.

Deficiency removed 09/05/24.
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Complaint investigation finding was amended to unsubstantiated.

Deficiency removed 09/05/24.
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Type B
09/05/2024
Section Cited
CCR
87413(a)(1)
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Complaint investigation finding was amended to unsubstantiated.

Deficiency removed on 09/05/24.
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Complaint investigation finding was amended to unsubstantiated.

Deficiency removed on 09/05/24
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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) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 15-AS-20230516162748
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: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited
HSC
1569.2(c)
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Complaint investigation finding was amended to unsubstantiated

Deficiency removed on 09/05/24
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Complaint investigation finding was amended to unsubstantiated.

Deficiency was removed on 09/05/24
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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) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
05/16/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230516162748

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: 109DATE:
09/05/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Brittany Karlinski, Administrator (ADM) / Executive DirectorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not assist resident with toileting
Facility staff did not inform resident's physicians and family of change in resident's condition
Facility staff did not follow resident's care plan
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/05/24 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent 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 – Resident roster with contact information, Personnel record (LIC500), pre-placement appraisal, admission agreements, needs & services plans, physician’s reports, Doctors’ orders, Activities of daily living schedules (ADLs), reappraisals, incident reports, notifications to authorized representative(s) / physicians of change in condition, Level of Care Notes, Hospital discharge reports.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 15-AS-20230516162748
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: 09/05/2024
NARRATIVE
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Allegation: Facility staff did not assist resident with toileting
Investigation Finding: Unsubstantiated
During investigation, the department reviewed R1’s signed appraisal report dated 01/23/20 and needs & services plan dated 05/05/20 which showed that R1 was assessed as independent with toileting, grooming, dressing and meals. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not assist resident with toileting 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 assist resident with toileting is unsubstantiated.

Allegation: Facility staff did not inform resident's physicians and family of change in resident's condition.
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s incident reports dated 03/25/20, 04/01/20, 04/29/20, 08/26/20 and 10/28/20 showed staff notified R1’s authorized representative (POA) and primary care physician (PCP) of these incidents involving R1’s unwitnessed falls in his bedroom and bathroom. Review of R1’s incident report dated 11/17/20 showed staff observed R1 grab the side of his head after an unwitnessed fall inside his bedroom. Staff called 911 and sent R1 to the hospital due to a change in condition. R1’s POA and PCP were both notified of the incident on 11/17/20.Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not inform resident’s physician and family of a change in resident’s condition 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 inform resident’s physician and family of a change in resident’s condition is unsubstantiated. Continued on next page, LIC 9099-C1
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 15-AS-20230516162748
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: 09/05/2024
NARRATIVE
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Allegation: Facility staff did not follow resident's care plan.
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s needs and services plans dated 05/05/20 and 07/27/20 showed staff provided R1 with his physician ordered special diet and daily medications, documented and reported to R1’s PCP of any missed doses or R1’s refusal of medications and total assistance with exit seeking behaviors by constantly monitoring R1 for attempts to leave the community. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did follow resident’s care plan 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 follow resident’s care plan is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8