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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200575
Report Date: 02/12/2026
Date Signed: 02/12/2026 05:14:05 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
02/05/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260205131220
FACILITY NAME:COMMONS AT DALLAS RANCH, THEFACILITY NUMBER:
079200575
ADMINISTRATOR:RFACILITY TYPE:
740
ADDRESS:4751 DALLAS RANCH ROADTELEPHONE:
(925) 754-7772
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:123CENSUS: 105DATE:
02/12/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marina Peckham, Assisted Living Director
Tangi Tingapaama, Director of Nursing		TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility did not administer resident's medications in a timely manner
Facility missed resident's blood pressure checks
Facility did not follow-up with resident's primary care physician on discontinued medication and refills in a timely manner
INVESTIGATION FINDINGS:
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On 02/12/26 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met and interviewed Assisted Living Director (ALD), Director of Nursing (DN), gathered information regarding the allegations and delivered investigation findings to ALD. LPA explained the purpose of the visit with ALD.

During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, ASLD) and obtained the following documents from ADM – Residents’ roster, Personnel Record (LIC500) / Work Schedules, Residents (R1, R2) admission agreements, needs & services plans, medication administration records, centrally stored medication logs, incident reports.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
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-20260205131220
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: 02/12/2026
NARRATIVE
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Allegation: Facility did not administer residents’ medications in a timely manner
Investigation Finding: Substantiated
On 02/12/26 at 3PM, LPA interviewed staff (ALD, Director of Nursing, S1) who stated that residents’ (R1, R2) medications were not administered in a timely manner because of S1’s failure to prioritize timely medication administration to residents on 02/01/26 because of two emergencies that happened around 10:30AM. S1 stated the other Med Tech on duty was busy helping other residents with their medications and could not assist her. Review of email documents dated 09/30/25, 10/02/25, 01/20/26 and 02/01/26 showed staff failed to administer R1 and R2’s medications in a timely manner and R1 had to call staff to give R2’s medications. Based on LPA’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 facility did not administer residents’ medications in a timely manner is substantiated.
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Allegation: Facility missed resident’s blood pressure checks
Investigation Finding: Substantiated
During investigation, LPA interviewed reporting party (RP) and staff (ED, ASL Director, S1). RP stated that R2’s twice daily blood pressure checks (one in the AM and another in the PM) were not being done by staff. ALD stated staff failed to perform R2’s blood pressure checks daily due to a lack of better training to fulfill residents’ care requirements. Based on LPA’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 facility missed resident’s blood pressure checks is substantiated.

Continued on next page, LIC 9099-C pg1
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20260205131220
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: 02/12/2026
NARRATIVE
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Allegation: Facility did not follow up with resident’s primary care physician on discontinued medication and refills in a timely manner
Investigation Finding: Substantiated
Review of email documents dated 09/30/25, 10/01/25, 10/02/25 and 10/03/25 showed R1’s ER discharge instructions to a skilled nursing facility (SNF) on 08/13/25 stated to stop taking Lisinopril. The 08/25/25 discharge notes from SNF to the facility did not have Lisinopril on R1’s medication list. Staff continued to administer Lisinopril to R! and failed to timely follow-up with his primary care physician (PCP) to remove Lisinopril from his medication list. Also, review of email dated 01/26/26 showed staff gave RP a package of his medications dated August 2025 which RP stated dosage was never received. Based on LPA’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 facility did not follow up with resident’s primary care physician on discontinued medication and refills in a timely manner is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) 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 a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20260205131220
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: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2026
Section Cited
CCR
87468.2(a)(4)
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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
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By POC due date, ALD agrees to complete and submit in-service staff retraining certifications on residents’ timely medication administration by an accredited CCLD vendor in compliance with Section 87468.2(a)(4) regulation.
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This requirement was not met as evidenced by staff failing to timely administer residents’ medications which posed a potential health & safety risk to resident in care.
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Type B
03/16/2026
Section Cited
CCR
87465(a)(1)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on residents’ medical care by an accredited CCLD vendor in compliance with Section 87465(a)(1) regulation.
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This requirement was not met as evidenced by staff failing to timely assist resident with blood pressure checks which posed a potential health & safety risk to resident in care.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20260205131220
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: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2026
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on residents’ proper medication administration by an accredited CCLD vendor in compliance with Section 87466 regulation.
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This requirement was not met as evidenced by staff failing to timely follow up with residents’ primary care physician to timely discontinue and/or administer refilled medications which posed a potential health & safety risk to resident in care.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5