079200575-1-22-2025-15-AS-BFOG-DDL35U-20250204165719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 01/22/2025
Date Signed: 01/22/2025 03:28:41 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
10/01/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20241001164317

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:	02:15 PM
MET WITH:	Diane Taylor, Director of Health Services		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff mismanaged resident’s medication

INVESTIGATION FINDINGS:

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On 01/22/25 at 2:15PM, 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, Resident's (R1) admission agreement, physician's reports, Needs & Services plans, hospital discharge reports (AVS), appraisals, Emails, Face Sheet, Progress Notes, Medication Administration records (September 2023 until current), 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: 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)

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Control Number 15-AS-20241001164317

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 mismanaged resident’s medication
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. Review of R1’s hospital discharge summary report (AVS) dated 09/27/23 - 09/29/23 time stamped 6:53PM showed R1 was diagnosed with acute confusional state. Attending hospital physician prescribed new anti-psychotic medication, 25mg Risperidone to be taken by R1 2X per day with instructions to stop administering bedtime anti-psychotic medication called Seroquel (Quetiapine 25mg) along with other medications. Review of emails between Executive Director (ED) and responsible party (POA) dated 08/16/24 and 09/27/24 confirmed that R1’s 09/27/23 -09/29/23 hospital discharge report time stamped 6:53PM was mis-filed in another resident’s binder. R1 received Seroquel (Quetiapine) until October 3rd which was replaced by Risperidone on October 4th when staff reviewed and noted R1’s AVS report dated 09/27/23 -09/29/23 on 10/03/23. Another refill of R1’s Seroquel (Quetiapine 25mg) was filled by R1’s pharmacy in December 2023. Review of R1’s medication administration records (MARs) written 12/16/23 showed R1 was administered two anti-psychotic medications, Seroquel (Quetiapine 25mg) and Risperidone 25 mg from 12/16/23 until 01/22/24. LPA observed no medication re-evaluation was conducted in December 2023 with R1's primary care physician to clarify if medication list is still valid. 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 mismanaged resident’s medication was found to be substantiated.

Deficiency is 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)

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Control Number 15-AS-20241001164317

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 87465(c)(1)	1 2 3 4 5 6 7	There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.	1 2 3 4 5 6 7	Plan of Correction (POC) completed on 01/22/25.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff mismanaged resident’s medication which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14	ED submitted copies of staff re-training dated 09/19/24 & 09/29/24 to CCL on proper medication management in compliance with Title 22 Section 87465 regulation
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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)

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