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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 04/25/2022
Date Signed: 05/06/2022 03:47:44 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
01/14/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220114181411
FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:DIANA BORZAFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 95DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Sheri KimbroTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility does not have sufficient staffing

Staff is not providing laundry service to residents
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 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 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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (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)
Page: 1 of 5
Control Number 27-AS-20220114181411
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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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.
Based on interviews conducted during the course of this investigation, it was learned that assistance with residents that needed assistance with laundry was neglected at that time. It was learned that due to the shortage of facility personnel, residents' clothes, linens, and bedding were not properly washed and sanitized, as stated on their assessments, upon admission into this facility.
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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (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)
Page: 5 of 5
Control Number 27-AS-20220114181411
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)
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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.
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This was previously investigated and cited on 04/25/2022 and even though the allegation was substantiated, no deficiency will be cited.
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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.
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Deficiency Dismissed
Type B
05/02/2022
Section Cited
CCR
87464(f)(4)
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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.
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This was previously investigated and cited on 04/25/2022 and even though the allegation was substantiated, no deficiency will be cited.
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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 laundry service. This presented a potential threat to the Health, Safety, and Personal Rights of the residents in care.
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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.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (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)
Page: 4 of 5
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
01/14/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220114181411

FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:DIANA BORZAFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 95DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Sheri KimbroTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Facility is providing an unsafe environment

Facility is not reporting COVID cases
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 residents, for the most part, have not experienced any mistreatment by the facility staff while receiving care or when asking for assistance. Facility residents understood the situation with staffing and the pressures that were placed on the facility personnel to perform their duties even with diminished numbers during the height of this pandemic.
Based on interviews conducted, it was learned that facility personnel were strained due to the lack of staffing but attempted to still provide care to the facility residents in a professional manner as best they could in order to foster a safe community.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (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)
Page: 2 of 5
Control Number 27-AS-20220114181411
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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Based on interviews conducted, facility residents did not feel that the facility staff were inappropriate when around providing care to them and felt safe at this facility at this time.
Based on a review of the forms and documents submitted into CCL from this facility, it was learned that all cases of COVID positive staff and residents were properly reported in a timely manner. Upon receipt of this information, CCL staff would document the report and a follow up call would be made out to this facility. This call was made in order to make sure that this facility was following the proper policies and procedures as outlined in the mandates from the California Department of Public Health and the Center for Disease Control. All calls were documented in the CCL system when reported by this facility and its personnel.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations 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
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (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)
Page: 3 of 5