392700366-11-21-2023-27-AS-LKIG-CY7NXA-20231204095047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 11/16/2023
Date Signed: 11/21/2023 05:52:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 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
08/16/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230816100215

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: 89	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sheri Kimbro		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff leave medications unattended making them accessible to residents

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 11/16/2023 by Licensing Program Analyst (LPA) Charlie Yang. This LPA 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 89 residents.
The purpose of this complaint visit was to deliver the findings for this investigation unto the facility and its representative at this time.
Based on interviews and a review of the facility policies and procedures involving handling, dispensing, and documentation of the resident medications, it was learned that resident medications were primarily stored in medication carts that were supposed to be locked and made inaccessible to the residents at all times. Facility personnel, (Medication Technicians), responsible for handling, dispensing, and documentation of the resident medications would maneuver the medication carts upon the designated times to dispense the medications to the residents. These medication technicians would then verify the medications prescribed to the resident and pour them accordingly and document once taken by the

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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-20230816100215

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COMMONS AT UNION RANCH, THE	FACILITY NUMBER: 392700366
	VISIT DATE: 11/16/2023

NARRATIVE

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residents via electronic medication administration record (e-MAR) system.
Based on interviews, it was learned that the medication cart was always maintained to be locked especially if facility personnel stepped away from it.
Based on interviews conducted there were no reports or accounts of any medications having been left out on the medication cart making them accessible to residents and visitors.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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