392700366-2-14-2023-27-AS-LKIG-CP5T78-20230217132819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 01/18/2023
Date Signed: 02/14/2023 05:24:57 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
11/04/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221104083852

FACILITY NAME:	COMMONS AT UNION RANCH, THE		FACILITY NUMBER:	392700366
ADMINISTRATOR:	SHERI KIMBRO		FACILITY TYPE:	740
ADDRESS:	2241 N UNION ROAD		TELEPHONE:	(209) 463-9100
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	135	CENSUS: 86	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sheri Kimbro		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility staff failed to follow resident's modified dietary restriction

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 01/8/2023 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 86 residents.
The purpose of this complaint visit was to deliver the findings for the above allegation.
Based on a review of the forms and documents, it was observed that R1 was admitted into this facility back in the early part of October 2022. It was learned that R1 was diagnosed to have a food allergy, specifically to peanuts, as stated on the LIC 602 that was signed and dated by the attending physician on 09/16/2022.
Additional documents that were reviewed, such as the Needs and Services Plan for R1, were completed, signed, and dated by a facility representative on 10/10/2022. This set of documents also stated that resident R1 was allergic to peanuts and required reminders at this time when it came to R1's meals.
Based on interviews conducted, it was learned that on 11/03/2022 around the time that lunch was being served, cookies were shorlty offered to the residents once they finished their meals. It was learned that the

Substantiated

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: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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-20221104083852

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: 01/18/2023

NARRATIVE

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cookies that were being offered to the residents were of the chocolate chip variety. It was learned that the chocolate chip cookies were all handed out to the residents who were present and additional cookies were requested to be made to accommodate the residents who did not receive a cookie. It was learned that the new cookies that were made were of the peanut butter variety and handed out to the residents. Resident R1 received this second batch of cookies and ate the peanut butter cookie. This led R1 to suffer from the allergies and symptoms associated with this medical condition requiring immediate medical care from the local medical facilities.
This facility was found to be deficient of the complaint allegation since they allowed a known resident diagnosed and documented with a food allergy, specifically to peanuts, to consume a food item that was a direct threat to the Health, Safety, and Personal Rights of the resident(s) in care.

As a result of this investigation, this LPA found the allegation 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, 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: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221104083852

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: 01/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/25/2023 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.	1 2 3 4 5 6 7	The facility designated Administrator stated that facility staff shall be sufficient and able to meet the needs of the residents at all times. Training, for no less than (1) hour in duration, will be conducted and completed for all facility staff providing care and supervision to the residents at this time. The topic shall cover the policies and procedures for this facility's
	8 9 10 11 12 13 14	This facility did not meet this requirement as evidenced by not following the assistance and care needs of the residents as indicated in their pre-admission appraisal for assistance in meals, food allergies, and eating. This presented an immediate threat to the Health, Safety, and Personal Rights of the residents in care.	8 9 10 11 12 13 14	meal service, food allergies, and ADLs delivered to the residents in care. A statement of correction, along with proof of training topic, trainer information, and list of attendees will be completed and submitted into CCL by the due date of 01/25/2023.
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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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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