079200575-4-29-2022-15-AS-BFOG-CF2QMR-20220603121757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 04/29/2022
Date Signed: 04/29/2022 05:49:30 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
02/09/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210209153826

FACILITY NAME:	COMMONS AT DALLAS RANCH, THE		FACILITY NUMBER:	079200575
ADMINISTRATOR:	ANDREWS, BRITANNY		FACILITY TYPE:	740
ADDRESS:	4751 DALLAS RANCH ROAD		TELEPHONE:	(925) 754-7772
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	123	CENSUS: 103	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	05:50 PM
MET WITH:	Micah Savage, Executive Director/Administrator		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Resident sustained a fractured back while in care
Staff did not seek medical attention for resident in a timely manner
Staff did not assist residents with ADLs in a timely manner

INVESTIGATION FINDINGS:

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On 04/29/22 at 5:50PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Resident sustained a fractured back while in care.
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, the facility failed to provide staff with Hoyer lift training prior to allowing them to transfer residents with the lift. R1’s needs & services plan documented that she required a 2-person assist with dressing, toileting, bathing and transfers. S1 and S2 were present and actively involved in transferring R1 at the time of the incident which occurred on 02/06/21. However, an operational error resulted in the lift falling over while transferring R1 who sustained a serious injury. Hospital discharge summary report dated 02/08/21 shows R1 was diagnosed with a lumbar spinal compression fracture. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

A $500 immediate civil penalty is assessed on this day for violation which resulted to the injury of R1. Civil penalty determination related to serious bodily injury is pending.

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: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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 5

Control Number 15-AS-20210209153826

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: 04/29/2022

NARRATIVE

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Allegation: Staff did not seek medical attention for resident in a timely manner.
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, the facility did not seek medical attention in a timely manner for resident (R1). Despite complaints by R1 of severe back pain for 2 days (Hoyer fall incident occurred on 02/06/21 at 0830 hours), the facility did not send R1 to the hospital until 2 days later (911 was called on 02/08/21 at 0900 hours). Hospital discharge summary shows R1 was diagnosed with a lumbar spinal compression fracture. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Staff did not assist residents with ADLs in a timely manner.
Investigation Finding: SUBSTANTIATED
Based on interviews conducted during investigation, staff (S1) stated residents are not being assisted in a timely manner due to insufficient staffing resulting in medication, feedings, showers, diaper changes and activities of daily living (ADLs) being done late or not at all. Resident (R2) stated that the facility was sometimes short staffed which affected the response time of the caregivers. Witness (W1) stated resident (R3) has lived at the facility for 2 years and 2 months. W1 stated that staff did not respond in a timely manner when R3 pressed her call pendant. R3 has had to wait 30 to 45 minutes for staff to respond. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
02/09/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210209153826

FACILITY NAME:	COMMONS AT DALLAS RANCH, THE		FACILITY NUMBER:	079200575
ADMINISTRATOR:	ANDREWS, BRITANNY		FACILITY TYPE:	740
ADDRESS:	4751 DALLAS RANCH ROAD		TELEPHONE:	(925) 754-7772
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	123	CENSUS: 103	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	05:50 PM
MET WITH:	Micah Savage, Executive Director/Administrator		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Incident not reported to licensing office

INVESTIGATION FINDINGS:

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Unfounded

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: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20210209153826

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: 04/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/29/2022 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	Personnel Requirements Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.	1 2 3 4 5 6 7	A $500 immediate civil penalty is assessed on this day for violation which resulted in the serious injury of R1. Civil penalty determination related to serious bodily injury is pending.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by resident sustaining a fractured back while in care which posed an immediate health & safety risk to resident in care	8 9 10 11 12 13 14	By POC due date, Administrator agreed to submit to CCLD proof of in-service staff retraining on Hoyer Lifts and proper safety transfer techniques. Deficiency cleared during visit, Administrator submitted copy of staff retraining on proper use of Hoyer lift on 04/29/22.
Type B 05/29/2022 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Medical & Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…	1 2 3 4 5 6 7	By POC due date, Administrator agrees to submit to CCLD proof of In service staff retraining on calling 911 and
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff not seeking timely medical attention for the resident which posed a potential health & safety risk to resident in care	8 9 10 11 12 13 14	report changes in condition to resident’s primary physician, authorized representative in a timely manner.

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: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20210209153826

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: 04/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/29/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Personal Rights To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	By POC due date, Administrator agrees to hire additional staff with proper training to ensure residents’ needs are timely met. Administrator will submit to CCLD proof of updated Personnel Record (LIC500) showing sufficient staff to meet residents’ care and supervision needs
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff not assisting residents with their ADLs in a timely manner which posed a potential health & safety risk to residents in care	8 9 10 11 12 13 14
	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: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5