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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 03/21/2024
Date Signed: 04/02/2024 05:29:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240122114208
FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:SHERI KIMBROFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 97DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Morgan WareTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff made an inappropriate comment about a resident
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/21/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Morgan Ware, and was briefly interviewed at this time.
Current census was 97 residents.
The purpose of this visit was to deliver the findings from this complaint investigation to the facility and its representative at this time.
Based on a review of the forms and documents gathered during the course of this investigation, it was learned that there was a facility staff person, S1, who was found to have made an inappropriate comment in regards to a resident in care.
This facility did suspend this particular staff person, S1, pending an internal investigation to the above allegation.
Based on the internal investigation conducted by facility personnel and department managers, the facility staff person, S1, did make an inappropriate comment in regards to a resident in care. This staff person,
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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-20240122114208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMMONS AT UNION RANCH, THE
FACILITY NUMBER: 392700366
VISIT DATE: 03/21/2024
NARRATIVE
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S1, was going to be allowed to return to work with a written warning of possible termination if this type of behavior occurred again in the future.
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 observed and 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 left with the facility designated Administrator at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240122114208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT UNION RANCH, THE
FACILITY NUMBER: 392700366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2024
Section Cited
CCR
87468.1(a)(1)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This facility was found to be deficient as
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The facility designated Administrator stated that all facility care staff will be in-serviced, for no less than (1) hour in duration, on the topics of Resident Personal Rights and upholding their dignity at all times. A statement of correction, along with proof of training, will be completed and submitted into
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evidenced by findings that facility staff did make an inappropriate comment in regards to a facility resident in care. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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CCL by the due date.
Proof of training will include the name of the trainer, topics of training, and a list of all attendees.
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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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3