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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 03/24/2025
Date Signed: 04/10/2025 10:17:27 AM

Substantiated


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
01/15/2025 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250115093855
FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:SHERYL BRAVOFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 107DATE:
03/24/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sheryl BravoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not transfer resident properly.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/24/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 107 residents.
The purpose of this visit was to inform this facility, and its representative, about the completion of this investigation and present the findings from this investigation at this time.
Based on interviews and a review of the forms and documents gathered during the course of this investigation, it was learned that there were (2) caregivers present when attempting to assist R1 in R1's bedroom. It was learned that the caregivers were present to assist R1 in transferring from R1's wheelchair to the bed.
It was learned that R1 was prompted to stand up even though R1 was unable to bear weight and prompted to grab a hold of the top of the headboard in order stand up and to avoid falling down. It was learned that after R1 grabbed the headboard and stood up, R1 was no longer able to stand on R1's own
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
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 5
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
01/15/2025 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250115093855

FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:SHERYL BRAVOFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 107DATE:
03/24/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sheryl BravoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/24/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met the facility designated Administrator Sheryl Bravo. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 107 residents.
The purpose of this visit was to inform this facility, and its representatives, about the completion of this investigation and the findings from this investigation at this time.
Based on interviews and a review of the forms and documents gathered during the course of this investigation, it was learned that there were (2) caregivers present when attempting to assist R1 in R1's bedroom. It was learned that the caregivers were present to assist R1 in transferring from R1's wheelchair to the bed since R1 was deemed to be unable to independently transfer and required assistance in doing so at all times.
It was learned that R1 was prompted by the facility caregiver to grab the headboard on R1's bed and to pull R1 up into a standing position next to R1's bed. It was learned that R1 attempted to do this and shortly
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250115093855
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: 03/24/2025
NARRATIVE
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thereafter could not maintain this standing position and had started to fall down.
It was learned that one of the facility staff reacted and pushed R1 onto R1's bed in order to avoid the resident falling onto the floor possibly sustaining additional injuries.
It was learned that facility staff then proceeded to reposition R1 in order to turn and pivot R1 to lay correctly in R1's bed. It was learned that the facility resident was solely dependent on the (2) caregivers to assist her in this process so that R1 could be repositioned correctly in R1's bed.
It was learned that the facility caregivers attempted to maneuver R1 in R1's bed without grabbing or pushing the resident excessively to prevent further injuries and bruising. It was learned that, at no point in this whole incident, did the facility caregivers climb onto R1 while trying to turn her. In addition, it was learned that the facility caregivers did not ever use their knees to push or pivot R1 while R1 was laying in the bed.

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 at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250115093855
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: 03/24/2025
NARRATIVE
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power and started to fall down.
It was learned that the caregivers who were present did not properly assist in this transfer which led to the eventual fall of R1.
As R1 was falling down, it was learned that one of the facility caregivers pushed R1 to one side onto the bed in order to avoid R1 from falling onto the floor and possibly sustaining additional injuries.
Based on interviews, it was learned that this was not the correct steps that facility caregivers should have taken in order to properly assist in the transfer of a resident. It was learned that the policies and procedures for an appropriate transfer of the residents were not correctly followed in order to avoid any further injuries and falls related to individuals unable to independently transfer.

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 left with the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250115093855
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2025
Section Cited
CCR
87468.1(a)(2)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This facility was found to be deficient as
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The facility designated Administrator stated that all facility staff providing care and supervision to all residents in care will be trained, for no less than (1) hour in duration, on the topic of proper assistance in transfer techniques. A statement of correction, along with proof of updated staff training, will be
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evidenced by the improper transfer of a facility resident by facility staff from their wheelchair onto their bed. This posed an immediate threat the Health, Safety, and Personal Rights of all residents in care.
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completed and submitted into CCL by the due date.
Proof of correction will include name of trainer, topic of training, and list of attendees.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5