079200575-1-22-2025-15-AS-BFOG-DDD39X-20250128170353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 01/22/2025
Date Signed: 01/22/2025 03:44:25 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
09/27/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240927112638

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: 88	DATE:	01/22/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Diane Taylor, Director of Health Services		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility
Staff do not ensure residents medications are securely stored in the facility

INVESTIGATION FINDINGS:

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On 01/22/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with Director of Health Services (DHS), gathered information relevant to the allegations and delivered investigation findings to DHS. LPA explained the purpose of the visit with DHS.

During investigation, LPA obtained the following documents from ED: Personnel record (LIC500), Residents' roster, Residents (R1, R2, R3, R4) admission agreements, face sheets, physicians' reports, reappraisals, Needs & Services plans, staff emergency /disaster drill quarterly records / training certifications, incident reports, house rules, staff personal rights training certifications.

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: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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 6

Control Number 15-AS-20240927112638

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: 01/22/2025

NARRATIVE

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Allegation: Staff do not ensure adequate supervision is provided resulting in residents eloping from the facility
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible partes and reviewed resident (R2, R3) documents. Review of incident reports dated 10/16/23 showed that at 11AM two memory care residents (R2, R3) were able to push open the memory care delayed egress side door and managed to walk outside the parking lot without the alarm sounding due to a faulty delayed egress system. LPA interviewed responsible parties (POAs) who stated that R2, R3 were found by a third party who alerted staff to escort them back to the memory care unit. Staff did not know that they were missing. 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 do not ensure adequate supervision is provided resulting in residents eloping from the facility was found to be substantiated.

Allegation: Staff do not ensure residents medications are securely stored in the facility
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. LPA reviewed video footage on 05/31/24 around 8:36PM which showed the memory care medication room door was unlocked/open with no staff present inside or outside the medication room. 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 do not ensure residents’ medications are securely stored in the facility 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: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 15-AS-20240927112638

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: 01/22/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/22/2025 Section Cited CCR 87705(e)(7)	1 2 3 4 5 6 7	Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents, including staff needed to escort residents who need supervision to leave the facility.	1 2 3 4 5 6 7	Plan of Correction (POC) completed on 01/22/25. DHS submitted copies of staff re-training on Care of Persons with Dementia dated 10/16/24 in compliance with Title 22 Section 87705 regulations
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff do not ensure adequate supervision is provided resulting in residents eloping from the facility which posed a potential health & safety risk to residents in care	8 9 10 11 12 13 14
Type B 01/22/2025 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication	1 2 3 4 5 6 7	Plan of Correction (POC) completed on 01/22/25. DHS submitted copies of staff re-training dated 09/19/24 & 09/29/24 on proper medication management in compliance with Title 22 Section 87465 regulations.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff failing to lock memory care medication room which posed a potential health & safety risk to residents in care	8 9 10 11 12 13 14

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: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
09/27/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240927112638

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: 88	DATE:	01/22/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Diane Taylor, Director of Health Services		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff do not ensure reporting requirements are being followed
Licensee does not ensure staff are trained in emergency evacuation procedures
Licensee does not ensure fire evacuation drills are conducted quarterly
Staff do not ensure resident is accorded personal privacy

INVESTIGATION FINDINGS:

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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: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 15-AS-20240927112638

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: 01/22/2025

NARRATIVE

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Allegation: Staff did not ensure reporting requirements are being followed
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed residents’ (R2, R3) documents. Review of incident reports dated 10/16/23 showed staff reported two memory care residents (R2, R3) were found walking outside the parking lot of the assisted living front doors when they were able to open the memory care side door without the alarm sounding due to a faulty delayed egress system. A third party alerted staff who escorted them back to the memory care unit. Staff notified R2 & R3’s responsible parties, Community Care Licensing (CCL) and Ombudsman of the incidents. 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 ensure reporting requirements are being followed is unsubstantiated.

Allegation: Licensee does not ensure staff are trained in emergency evacuation procedures
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ED, DHS, WCD) who stated that the facility’s Emergency Disaster plan for the Elderly is reviewed and discussed monthly in staff meetings with assignments executed during an emergency evacuation – Environmental Director (EVD) to direct evacuation & person count, Director of Health Services (DHS) to handle first aid, Memory Care Director (MCD) to supply updated telephone emergency numbers, Wellness Program Director (WCD) to coordinate transportation & rally points, Business office manager (BOM) to notify responsible parties of any emergency evacuation and Executive Director to notify Community Care Licensing and other agencies. 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 Licensee does not ensure staff are trained in emergency evacuation procedures is unsubstantiated.

Continued on next page, LIC 9099-C1

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 15-AS-20240927112638

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: 01/22/2025

NARRATIVE

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Allegation: Licensee does not ensure fire evacuation drills are conducted quarterly
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ED, DHS, S2, S3) who stated that fire and earthquake evacuation drills are conducted quarterly with written documentation kept for reference. Annual fire inspections were also conducted with the local fire department staff in addressing any issues with regards to fire safety and equipment. LPA reviewed quarterly fire evacuation drill records completed in 2023 and 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 staff did not communicate with resident’s responsible party is unsubstantiated.

Allegation: Staff do not ensure resident is accorded personal privacy
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (S2, S3, S4) who stated that they treat each resident with dignity and respect. They conduct status checks on each shift to ensure each resident’s needs are met such as diaper changes, toileting, dressing, grooming, transfers, bathing and personal hygiene. They denied violating residents’ privacy. 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 do not ensure resident is accorded personal privacy is unsubstantiated.

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: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC9099 (FAS) - (06/04)

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