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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700366
Report Date: 05/03/2021
Date Signed: 05/12/2021 08:30:12 AM



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
03/04/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210304150554
FACILITY NAME:COMMONS AT UNION RANCH, THEFACILITY NUMBER:
392700366
ADMINISTRATOR:MAUREEN BRADLEYFACILITY TYPE:
740
ADDRESS:2241 N UNION ROADTELEPHONE:
(209) 463-9100
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:135CENSUS: 90DATE:
05/03/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maureen BradleyTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not give resident medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings into allegation listed above. LPA met with administrator during today's inspection.

During complaint investigation LPA reviewed records. During the review of records, LPA observed in R1's file documentation that R1 moved into the facility on 12/29/2020 and passed away on hospice on 1/6/2021. The documentation further details that the facility did not provide R1 with medication on the 5th and 6th of January 2021. The documentation confirms that R1 was observed to be unresponsive on January 4th, 2021 at 6:16pm this was noted by the facility nurse (FN). The FN called and left messages on 1/4/2021 for hospice agency requesting a wellness visit and there was also call to R1's sister to update the family on the change in condition.

Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
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-20210304150554
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: 05/03/2021
NARRATIVE
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The facility confirmed that on the 4th of January 2021 after observing R1 was unresponsive the Med-techs did not provide R1 with prescribed medications for the 5th and 6th of January 2021. The facility did not contact or report this information to R1's Physician, hospice or to the Department (Community Care Licensing). As a result of the investigation the department find that Staff did not give resident medications or document that it was given for the 5th and 6th of January 2021 the allegation is substantiated.

Based on records reviewed and interviews which were conducted the preponderance of evidence standards has been met, therefore, the above allegation(s) is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed, Copy of report given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210304150554
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: 05/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2021
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
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The Administrator has developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. The agenda along with the sign-in sheet was given during the investigation.
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This requirement is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents are given as prescribed which posses an immediate health and safety risk to residents in care.
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The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.
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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: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3