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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 09/29/2022
Date Signed: 10/10/2022 04:49:39 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220505095737
FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:DIANA BORZAFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 87DATE:
09/29/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sheri KimbroTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff is not following Physician order to D/C Medication
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 09/29/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Sheri Kimbro. A brief interview was conducted with the facility designated Administrator at this time.
Current census was residents.
Based on interviews conducted during the course of this investigation, it was learned that R1 was prescribed for a medication, Benazepril HCL (Lotensin) 5 mg, which was ordered to be dispensed once daily in a tablet form. It was learned that facility medication technicians dispensed this medication daily to R1 without any issues of the medication being refused, missed, or lost.
Based on a review of the Medication Administration Record and personal file for R1, it was observed that this particular medication was initially discontinued by the attending physician for R1. The date for discontinuance for this medication was faxed into this facility on 04/19/2022 as evidenced by the document signed by a physician from the Bacay Medical Associates, Inc. It was learned that due to an issue with communication and filing of this fax, the medication technicians did not see this fax for discontinuance until
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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 3
Control Number 27-AS-20220505095737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COMMONS AT UNION RANCH, THE
FACILITY NUMBER: 392700366
VISIT DATE: 09/29/2022
NARRATIVE
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6 days later. It was learned that the discontinued medication, Benazepril HCL (Lotensin) 5 mg, was still being dispensed even though the fax had already been sent over to this facility.
As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator Sheri Kimbro.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220505095737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COMMONS AT UNION RANCH, THE
FACILITY NUMBER: 392700366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care
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
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Facility designated Administrator stated that a plan for reviewing faxes and documents from the responsible physicians for facility staff will be implemented in order to eliminate the possibility of lost or misplaced crucial documents regarding resident care and medication needs. In addition, facility medication technicians will need to be trained,
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appropriate to the conditions and needs of residents.
This facility was deficient as evidenced by not following the discontinuance notice for a prescribed medication provided by the attending physician for a facility resident. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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for no less than (1) hour in duration, in the areas of proper communication, handling/dispensing, and documentation of facility resident medications. Proof of facility staff training and plan for incoming documents will be completed and submitted into CCL by the due date of 10/06/2022.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3