392700366-4-2-2024-27-AS-LKIG-D46KX9-20240409081710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 03/21/2024
Date Signed: 04/02/2024 05:27:51 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, 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
01/29/2024 and conducted by Evaluator Charlie Yang

COMPLAINT CONTROL NUMBER: 27-AS-20240129143242

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: 97	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Morgan Ware		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility does not have a qualified Administrator

Staff do not follow procedures to prevent the spread of illness

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 the current facility designated Administrator, Sheri Kimbro, was certified with an Administrator Certificate #7014585740 that was set to expire on 01/25/2024. A review of the Administrator Certification Bureau information system revealed that this certificate number #7014585740 was renewed with all required hours completed and applicable fees paid. A new expiration date was then set for 01/25/2026.
Based on a review of this facility's infection control plan and requirements set forth from the Department of Public Health, this facility was required to do response testing since it was under quarantine for COVID

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (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)

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Control Number 27-AS-20240129143242

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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positive staff and residents that were reported to CDSS and the Department of Public Health.
It was learned that facility personnel were required to come to this facility for response testing until clearance from the Department of Public Health. It was learned that facility staff who tested negative were allowed to enter the lobby area and get tested on a weekly basis. On the other hand, positive staff and those who were exhibiting symptoms, were not allowed to enter the facility premises and were tested out in their vehicles as designated staff persons met them out there.
Based on interviews, it was learned that there were not any incidents where facility staff persons broke protocol and entered the premises with a COVID positive test to endanger the facility staff and other facility residents. It was learned that the policies and procedures were followed until the quarantine was eventually lifted by the Department of Public Health.

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 were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (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)

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