392700366-4-8-2021-27-AS-LKIG-C252Z4-20210415174942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 04/08/2021
Date Signed: 04/08/2021 09:44:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/17/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201117090241

FACILITY NAME:	COMMONS AT UNION RANCH, THE		FACILITY NUMBER:	392700366
ADMINISTRATOR:	MAUREEN BRADLEY		FACILITY TYPE:	740
ADDRESS:	2241 N UNION ROAD		TELEPHONE:	(209) 463-9100
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	135	CENSUS: 92	DATE:	04/08/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maureen Bradley, Executive Director		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Resident sustained a fracture while in care due to neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bruce Jacobs contacted the facility and spoke with Executive Director Maureen Bradley to deliver investigation findings on the above allegation. This investigation was conducted by the Department and consisted of site inspections and interviews with facility residents (R-1,2,3,4), staff (S-1,2,3,4,5,6,7), management and other witnesses. Medical and facility records for resident (R-1) were obtained and reviewed. Staffing schedules were received and reviewed.

This investigation concludes that a resident (R-1) had a severe fall on the evening of July 12, 2020 and was hospitalized as a result of the fall and was treated for a hip fractures. The care plan/resident assessment of 5/27/2020 and interviews with staff document that the resident was a two person assist for transfers. Two staff members (S-4,7) assisted the resident into the bathroom, but only one staff (S-4) was assisting after the resident had finished using the bathroom. While the resident was being transferred by one staff member, the resident's legs buckled and the resident fell on the floor, fracturing her hip. Staff (S-7) was observed in the resident's (R-1) room, but not assisting the resident.

Interviews and records document that the resident was a fall risk and a two person assist for transfers was required. (continued)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

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 4

Control Number 27-AS-20201117090241

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: 04/08/2021

NARRATIVE

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As a result of this investigation, Licensing has determined the above allegations is (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.

At the time of the conclusion of this complaint investigation, the issuance of a Civil Penalty was still being determined. However, the Licensee was informed that a Civil Penalty may be assessed based on Health & Safety Code section 1569.49.

Exit interview conducted and report provided. Appeals rights printed

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/17/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201117090241

FACILITY NAME:	COMMONS AT UNION RANCH, THE		FACILITY NUMBER:	392700366
ADMINISTRATOR:	MAUREEN BRADLEY		FACILITY TYPE:	740
ADDRESS:	2241 N UNION ROAD		TELEPHONE:	(209) 463-9100
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	135	CENSUS: 92	DATE:	04/08/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maureen Bradley, Executive Director		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff were not trained or sufficient in numbers to provide services necessary to meet the residents' needs.

Staff not meeting the residents' incontinence needs.

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs conducted a phone call to discuss and deliver complaint findings for the allegations listed above. LPA spoke with Maureen Bradley, Executive Director to discuss these complaint findings.

The investigation was conducted by LPA Jacobs consisted of interviews with the Executive Director, facility staff, residents and other witnesses at the care home. Facility site inspections were conducted and records were reviewed and copies of pertinent documents including staffing and resident records were obtained for the complaint record. The investigation was unable to prove with a preponderance of evidence that the facility staff are not properly training or in sufficient numbers to provide services for the resident and not meeting their needs. Records and interviews document that facility schedules the appropriate number of properly trained care staff on a regular schedule. The facility did operate at a less than optimal level due to several infectious disease outbreaks, but the facility was able to fill the shortages by bringing in caregivers from a staffing agency and by having staff work extended shifts to meet the residens' needs.

This agency has investigated the above listed allegation and determined that there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, we have found the allegations to be UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20201117090241

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: 04/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/13/2021 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	Basic Services (f) Basic services shall at a minimum include: 4) 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...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Plan of Correction: Facility Administrator will develop a plan to ensure that the staffing is sufficiently trained on the resident's care plan and the plan is followed Also, care staff are properly trained to perform their basis duties to meet the needs of residents. A written Plan of Correction detailing how the facility will meet this requirement will be submitted to
	8 9 10 11 12 13 14	Staff interviews and reviews of the resident's (R-1) care plan called for a two person assist and only one staff member was assisting the resident during a transfer and the resident fell. The resident landed on the floor, was taken to the hospital and was diagnosed with a fractured hip. This is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Licensing by 04/13/21 and the plan is to be completed by 4/30/21
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

LIC9099 (FAS) - (06/04)

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