392700366-10-10-2022-27-AS-LKIG-CL2PV9-20221110103843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 09/29/2022
Date Signed: 10/10/2022 03:44:26 PM

Unsubstantiated

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
04/12/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220412113421

FACILITY NAME:	COMMONS AT UNION RANCH, THE		FACILITY NUMBER:	392700366
ADMINISTRATOR:	DIANA BORZA		FACILITY TYPE:	740
ADDRESS:	2241 N UNION ROAD		TELEPHONE:	(209) 463-9100
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	135	CENSUS: 87	DATE:	09/29/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Sheri Kimbro		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is not following the prescribed diabetic diet for the resident

Facility is not administering medications as ordered

Staff not properly trained

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 diagnosed with Type II Diabetes and required a mechanical diet and sugar free meals. It was learned that facility wait staff and kitchen staff were aware of these issues with R1 and prepared meals accordingly and always offered sugar free meal items to R1.
Based on a review of the Medication Administration Record and personal file for R1, it was observed that all medications (14 prescribed) and (8) PRN medications were documented on the QuickMAR dispensing log system for this facility. There were no discrepancies observed for missing medications, lost meds, or meds that were refused by the resident R1 at this time.
Based on a review of the facility personnel records and training logs, it was observed that staff who were

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (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)

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Control Number 27-AS-20220412113421

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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duly responsible for handling, dispensing, and documenting medications were properly trained and documented as such. It was learned that the medication technicians were trained monthly in addition to the annual requirements for medication training.
As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (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)

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