392700366-11-21-2023-27-AS-LKIG-CY7NYC-20231204095232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 11/16/2023
Date Signed: 11/21/2023 05:52:15 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, 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
09/13/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230913092220

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:	01:00 PM
MET WITH:	Sheri Kimbro		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not adequately assist a resident with showering, resulting in a fall.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 the evidence that was gathered throughout the course of this investigation, it was learned that a resident, R1, was deemed to be a full assist whenever R1 was in the restroom for a shower. It was learned that this meant the facility had a caregiver solely responsible for all of R1's care needs while R1 was taking a shower. This caregiver would be responsible to wash, soap, and assist the resident in/out of the shower so as to avoid any slips or falls while in the shower.
Based on a review of the facility forms and documents for R1, this particular resident experienced (2) falls while taking a shower even though it was determined that R1 required a dedicated staff person to be present

Substantiated

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)

Page: 1 of 3

Control Number 27-AS-20230913092220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

to assist at all times. This resident was deemed to be a full assist upon initial assessment and admission to this facility.
It was learned that there were no other documented reports of any other facility residents sustaining any slips/falls who were also deemed to be a full assist for showers.

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 given to the facility designated Administrator 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)

Page: 2 of 3

Control Number 27-AS-20230913092220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 11/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 11/17/2023 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	Basic services shall at a minimum include: 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, as specified in Section 87608.	1 2 3 4 5 6 7	The facility designated Administrator stated that a review of all full assist resident care plans for showers will be conducted. A statement of correction, along with updated facility staff training for no less than (1) hour in duration on the topic of full assist with resident showers, will be completed and
	8 9 10 11 12 13 14	This facility was found to be deficient as evidenced by a facility resident sustaining (2) separate falls even though their initial assessment required a caregiver to be present at all times while showering posing an immediate threat to the Health, Safety, and Personal Rights of residents in care.	8 9 10 11 12 13 14	submitted into CCL by the due date.
	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: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3