392700366-2-14-2023-27-AS-LKIG-CP5T2Q-20230217132106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 01/18/2023
Date Signed: 02/14/2023 04:26:05 PM

Unsubstantiated

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
11/09/2022 and conducted by Evaluator Charlie Yang

COMPLAINT CONTROL NUMBER: 27-AS-20221109143103

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:	11:30 AM
MET WITH:	Sheri Kimbro		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff failed to keep resident clean and dry from incontinence.

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 be able to dress/groom one self, feed one self, and care for his/her own toileting needs, as stated on the LIC 602 that was signed and dated by the attending physician on 09/16/2022. It was learned that R1 was diagnosed to not have any bowel or bladder impairment as well.
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 independent of any toileting assistance at the time of admission and overall assessement.

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: 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-20221109143103

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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It was also documented that R1 was able to independently transfer and did not need any assistance with toileting as indicated on the Resident Assessment that was signed by all parties on 10/11/2022.

As a result of this investigation, this Department found the allegation 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: 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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