392700366-8-27-2024-27-AS-KHOS-D8QNXS-20240902105137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 08/19/2024
Date Signed: 08/27/2024 06:22:56 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
05/13/2024 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240513143948

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: 98	DATE:	08/19/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sheryl Bravo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff mishandled a resident's medication while in care.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 08/19/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 98 residents.
The purpose of this visit was to deliver the findings of this complaint investigation to this facility and it's designated representative at this time.
Based on interviews and a review of the forms and documents conducted during the course of this investigation, it was learned that R1 did not have a history of missing or not having the prescribed medications. There weren't any documented incidents where it was observed that R1 did not receive R1's medications as prescribed by his/her responsible licensed medical professional or ran out of them while under the care of this facility since being admitted on 02/24/2022.
It was learned that since the filing of this complaint, there have not been any further incidents reported in
regards to R1's medications not being administered or mishandled by facility medication technicians.

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: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

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-20240513143948

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: 08/19/2024

NARRATIVE

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Based on interviews conducted during the course of this investigation, it was learned that a pill for R1 was found in R1's room which may have appeared that R1 did not properly take the medication as prescribed for that day. It was learned that on the date of the reported incident of the pill being discovered, R1 was in the dining area of this facility where R1 took all of R1's prescribed medications without any issues. It was learned that it would have been difficult for the lone pill to appear in the room of R1 when R1 would have taken all of his/her prescribed medications in a different area on that day without any incident.

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 during today's complaint visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

LIC9099 (FAS) - (06/04)

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