392700366-5-6-2022-27-AS-SDOB-CHCPGU-20220816111851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 04/25/2022
Date Signed: 05/06/2022 04:21:15 PM

Substantiated

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
01/12/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220112104530

FACILITY NAME:	COMMONS AT UNION RANCH, THE		FACILITY NUMBER:	392700366
ADMINISTRATOR:	DIANA BORZA		FACILITY TYPE:	740
ADDRESS:	2241 N UNION ROAD		TELEPHONE:	(209) 463-9100
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	135	CENSUS: 95	DATE:	04/25/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Sheri Kimbro		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are not responding to pull cords timely

Residents are not getting showers due to lack of staff

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility by Licensing Program Analyst (LPA) Charlie Yang on 04/25/2022 and was met by the facility designated Administrator Sheri Kimbro. A brief interview was conducted with the facility designated Administrator.
Current census was 95 residents.
The purpose of this complaint visit was to conclude this investigation and present the findings to the facility designated Administrator.
Based on interviews conducted during the course of this investigation, it was learned that due to the shortage of facility staff, residents' hygiene needs were being neglected at that time. It was learned that showers, assistance with Activities of Daily Living, and grooming assistance was not provided as outlined in the Needs and Services Plans for the residents.
Based on interviews conducted during the course of this investigation, it was learned that residents would often times activate their pendants, or pull cords, for a variety of reasons requiring assistance from the facility staff. It was learned that upon activation, a signal would be sent to the front desk notifying them that a

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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-20220112104530

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: 04/25/2022

NARRATIVE

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resident required assistance indicating the room number. Facility staff were then supposed to respond to the request or, in the event that they were assisting another resident, call out to their peers for assistance in order to properly respond in a timely manner. It was learned that residents were left to simply wait until facility staff were able to get to them before resetting the pendant or pull cord to signal that they had responded.
Based on a review of the forms and documents provided by this facility for the call logs and response times of the facility staff, it was learned that facility staff did not respond in a timely manner. Call logs dating back to November 2021 until January 2022 revealed that facility residents would sometimes have to wait up to 20 minutes before facility staff were able to respond to their calls for assistance. In addition, there were response times from facility staff which even exceeded 30 minutes before responding to the call buttons from the residents.
As a result of this investigation, this LPA found the allegations 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 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, reviewed, and a copy was left with the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220112104530

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: 04/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/02/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports.	1 2 3 4 5 6 7	This was previously investigated and cited on 04/25/2022 and even though the allegation was substantiated, no deficiency will be cited.
	8 9 10 11 12 13 14	This facility was observed to be deficient as evidenced by the lack of staff to properly respond to residents' activation of their pendants in a timely manner. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type B 05/02/2022 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, Postural Supports.	1 2 3 4 5 6 7	This was previously investigated and cited on 04/25/2022 and even though the allegation was substantiated, no deficiency will be cited.
	8 9 10 11 12 13 14	This facility did not meet this requirement as evidenced by not following the assistance and care needs of the residents as indicated in their pre-admission appraisal for proper hygiene care and showers. This presented a potential threat to the Health, Safety, and Personal Rights of the residents in care.	8 9 10 11 12 13 14

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC9099 (FAS) - (06/04)

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