Inspection Reports for The Commons at Dallas Ranch

An unannounced complaint investigation was conducted due to an allegation that staff did not process residents' insurance invoices in a timely manner for reimbursement.

The allegation was substantiated. The investigation found that six residents' insurance invoices were not processed timely due to a change in management, posing a potential health and safety risk to clients in care. The deficiency was cited under Title 22 California Code of Regulations.

The complaint was substantiated based on interviews and record reviews. Six residents' insurance invoices were confirmed by the Executive Director to have not been processed timely due to management changes.

An unannounced complaint investigation was conducted due to an allegation that staff does not ensure resident's medical information is confidential.

The allegation was substantiated after interviews and observations confirmed that staff publicly discussed resident’s medical information at the front desk, violating residents’ personal rights and posing a potential health and safety risk.

The complaint was substantiated based on interviews with staff and observations that staff publicly discussed resident’s medical information at the front desk on 08/06/25, violating residents’ personal rights.

The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to assess compliance with licensing requirements.

The inspection found no deficiencies. The facility was observed to have proper infection control measures, emergency plans, sufficient food and PPE supplies, operational safety equipment, and monthly fire and earthquake drills.

Unannounced complaint investigation visit conducted due to allegations that staff administered unauthorized medication to a resident and disclosed personal information about a resident.

Both allegations were substantiated after interviews and record reviews. Staff administered unauthorized medication to a resident due to a delayed prescription refill and publicly disclosed a resident's personal medication information in a common area.

The complaint investigation was substantiated. Staff administered unauthorized medication to a resident on 04/16/25 at 12PM and disclosed personal information about the resident on the same date. The investigation included interviews with staff and review of resident and medication records.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-11-21 alleging that staff did not afford a resident privacy while in care.

The investigation included interviews with facility staff and the responsible party, review of resident documents and video evidence. The allegation was found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.

Allegation: Staff did not afford a resident privacy while in care. Investigation Finding: Unsubstantiated. The reporting party stated that on 08/01/24 a care provider was seen on video looking in a resident's closets and dresser drawers without permission. Staff denied the violation. The evidence was insufficient to prove the allegation.

The inspection visit was an unannounced complaint investigation triggered by an allegation that staff mismanaged a resident's medication.

The investigation substantiated the allegation that staff mismanaged a resident's medication, resulting in the resident receiving two anti-psychotic medications simultaneously due to misfiling of hospital discharge reports and lack of medication re-evaluation.

The complaint was substantiated. The investigation included interviews with facility staff and the resident's responsible party, and review of resident documents including hospital discharge summaries, medication administration records, and emails. The resident was administered two anti-psychotic medications simultaneously from December 16, 2023, to January 22, 2024, due to misfiling of hospital discharge reports and lack of medication re-evaluation.

The inspection was an unannounced complaint investigation visit conducted due to allegations including inadequate supervision resulting in resident elopement and unsecured medication storage.

Two allegations were substantiated: staff failed to provide adequate supervision leading to residents eloping due to a faulty delayed egress system, and staff failed to securely store residents' medications as the medication room door was found unlocked. Other allegations related to reporting, staff training on emergency evacuation, fire drills, and resident privacy were unsubstantiated.

The complaint investigation was substantiated for allegations that staff did not ensure adequate supervision resulting in residents eloping and that medications were not securely stored. Other allegations regarding reporting requirements, staff training in emergency evacuation, fire drills, and resident privacy were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff left a resident on the floor for an extended period of time, did not ensure resident hydration resulting in dehydration, and failed to communicate with the resident's responsible party.

The allegation that staff left a resident on the floor for an extended period was substantiated based on interviews, document reviews, and observations. The allegations that staff did not ensure resident hydration and did not communicate with the resident's responsible party were found to be unsubstantiated.

The complaint investigation was substantiated for the allegation that staff left a resident on the floor for an extended period of time. The resident had an unwitnessed fall on 11/29/24 and was found confused and lethargic with blood on his elbow. The resident was hospitalized for altered mental status due to dementia precipitated by dehydration and rhabdomyolysis. The allegations that staff did not ensure hydration and did not communicate with the resident's responsible party were unsubstantiated.

Unannounced complaint investigation visit conducted in response to allegations received on 2023-05-16 regarding staffing sufficiency, resident falls, and assistance with activities of daily living.

The complaint allegations were found to be unsubstantiated during the investigation. No deficiencies were cited, and amended reports were re-delivered as unsubstantiated.

Complaint control number 15-AS-20230516162748 involved allegations that the facility did not have sufficient staff to meet resident needs, residents sustained multiple unwitnessed falls resulting in injury, and staff did not assist residents with activities of daily living in a timely manner. The investigation concluded these allegations were unsubstantiated.

Unannounced complaint investigation visit conducted in response to allegations including improper COVID-19 control protocols, failure to prevent and properly care for residents' pressure injuries, and failure to ensure the facility is free of pests.

All allegations were investigated through staff interviews, document reviews, and facility inspections. The investigation found no preponderance of evidence to substantiate any of the allegations. The facility was found to follow COVID-19 protocols, provide proper wound care, and address pest issues effectively.

The complaint included allegations that staff did not follow proper COVID-19 control protocols, did not prevent residents from developing pressure injuries, did not properly care for residents' pressure injuries, and did not ensure the facility was free of pests. All allegations were found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-05-16 regarding staffing sufficiency, resident falls, and timely assistance with activities of daily living.

All allegations investigated were found to be unsubstantiated after review of resident records, staff and resident interviews, and documentation. No deficiencies were cited during the visit.

The complaint included allegations that the facility did not have sufficient staff to meet resident needs, a resident sustained multiple unwitnessed falls resulting in injury, and staff did not assist residents with activities of daily living in a timely manner. Each allegation was investigated and found unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced annual required inspection conducted to evaluate the facility's compliance with regulatory standards.

The inspection found no deficiencies. The facility was observed to have proper infection control measures, emergency plans, adequate supplies, and operational safety equipment.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not providing adequate housekeeping services to residents and were not ensuring residents were provided with toiletries.

The investigation found both allegations to be unsubstantiated after interviews, records review, and observations. Housekeeping services were found adequate and residents were responsible for their own toiletries as per admission agreements.

The complaint investigation was unsubstantiated. Allegations included inadequate housekeeping services and failure to provide toiletries. The department found no preponderance of evidence to prove the alleged violations occurred.

Unannounced complaint investigation visit conducted due to allegations that staff did not ensure medication was dispensed as prescribed and medication records were not properly maintained.

Both allegations were substantiated after interviews, record reviews, and observations. Medication was administered at incorrect dosages and medication records were not properly updated, posing potential health and safety risks to residents.

Complaint investigation was substantiated based on evidence including interviews, incident reports, and medication records showing incorrect medication dosage and improper record maintenance.

Unannounced complaint investigation visit conducted in response to allegations that staff were mismanaging resident medication and not meeting resident needs.

The investigation found both allegations to be unsubstantiated after reviewing medication administration records, conducting staff and resident interviews, and observing facility operations. No deficiencies were cited.

The complaint alleged staff mismanagement of resident medication and failure to meet resident needs. Both allegations were investigated and found unsubstantiated, meaning there was insufficient evidence to prove the violations occurred.

An unannounced complaint investigation visit was conducted in response to allegations that staff did not keep the facility free from bedbugs and pests.

The investigation substantiated the allegations of bed bug infestation and pest presence in the facility, posing potential health and safety risks to residents. The facility took corrective actions including scheduling extermination treatments and addressing mice infestation.

The complaint investigation was substantiated. Allegations included failure to keep the facility free from bedbugs and pests. Evidence showed bed bug infestations in resident apartments and memory care areas, and mice presence in kitchen and resident bedroom areas. Corrective actions were documented and deficiencies cleared during the visit.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-02-23 regarding illegal eviction of a resident and failure to ensure the resident's call system was operable.

Both allegations were investigated and found to be unsubstantiated. The facility followed proper procedures for eviction with a 30-day written notice due to resident's noncompliance, and the call system issue was promptly repaired with monthly checks in place. No deficiencies were cited.

The complaint involved two allegations: 1) Facility illegally evicted a resident in care, and 2) Facility did not ensure that resident's call system was operable. Both allegations were found unsubstantiated after review of documentation, interviews, and incident reports.

An unannounced Case Management visit was conducted regarding an incident reported on 2024-06-14 where a resident (R1) eloped from the memory care unit.

The licensee did not comply with staff responding timely before R1 eloped outside the building and across the street, posing a potential health and safety risk. The deficiency was cited but cleared during the visit after review of policies and corrective actions.

Complaint investigation regarding an incident of resident elopement on 2024-06-14. The incident was substantiated by findings of staff delay in response.

An unannounced Case Management visit was conducted regarding an incident reported to CCLD on 06/18/2024 concerning a resident delinquent with monthly rent payments.

The visit found that the resident's Responsible Party was offered payment arrangements but continued to miss payments. No deficiencies were issued during the visit.

The complaint involved a resident delinquent with monthly rent payments since move-in, with the Responsible Party failing to comply with offered payment plans.

An unannounced complaint investigation was conducted in response to an allegation that staff do not follow proper food sanitation and safety practices.

The investigation included interviews with staff and review of relevant documents. Observations and staff statements indicated proper hand washing and glove changing practices. The allegation was found to be unsubstantiated with no deficiencies cited.

The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violation occurred.

The inspection was an unannounced complaint investigation visit conducted in response to allegations including questionable death and staff not dispensing medication to residents in a timely manner.

The investigation found both allegations to be unsubstantiated after review of medical records, medication logs, interviews with staff and residents, and observations. There was no evidence of neglect or improper medication administration.

The complaint included allegations of questionable death and staff not dispensing medication to residents in a timely manner. Both allegations were investigated and found to be unsubstantiated based on records review, interviews, and observations.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including resident falls due to staff neglect, improper COVID-19 isolation, inadequate food service, improper sanitizing methods, delayed response to call buttons, and unclean resident rooms.

All allegations investigated were found to be unsubstantiated after review of records, interviews, and observations. The department found no preponderance of evidence to prove any violations regarding resident falls, COVID-19 isolation, food service adequacy, sanitizing methods, call button response times, or cleanliness of resident rooms.

The complaint investigation was unsubstantiated. Allegations included multiple residents falling due to staff neglect, failure to isolate COVID-19 residents, inadequate food service, improper sanitizing, untimely response to call buttons, and failure to clean residents' rooms. Investigations included interviews, document reviews, and observations, all resulting in unsubstantiated findings.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-06-15 regarding staff mismanagement of resident's medication and untimely medication refills.

The investigation substantiated allegations that staff mismanaged a resident's medication and did not order medication refills in a timely manner, posing potential health and safety risks. Other allegations including resident weight loss, falls, UTIs, dehydration, and insufficient staffing were found to be unsubstantiated.

The complaint investigation was substantiated for allegations of medication mismanagement and untimely medication refills. Other allegations including resident lost severe weight, sustained a fall, sustained UTIs, dehydration, and insufficient staffing were investigated and found unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-09-09 regarding staff overmedicating a resident and not following doctor's orders, among other complaints.

The investigation substantiated allegations that staff overmedicated a resident and did not follow doctor's orders, citing medication errors and failure to verify physician's orders. Other allegations related to safeguarding resident property, notifying POA of changes or incidents, responding to POA, and ensuring hygiene care were found unsubstantiated.

The complaint investigation was substantiated for allegations that staff overmedicated a resident and did not follow doctor's orders. Other allegations including failure to safeguard resident's property, failure to notify POA of changes or incidents, failure to respond to POA, and failure to ensure hygiene care were unsubstantiated.

The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with regulatory standards.

The facility was found to be clean, in good repair, and compliant with infection control and safety requirements. No deficiencies were cited during the visit.

The inspection was conducted as a result of the department receiving a priority 1 complaint to perform a health and safety check.

During the health and safety check, 25 staff members and 83 residents were observed. The facility was toured including bedrooms, kitchen, bathroom, and common areas. Residents appeared safe with no imminent health or safety concerns and no deficiencies were cited.

The visit was triggered by a priority 1 complaint. No deficiencies were cited and no imminent health or safety concerns were found.

An unannounced complaint investigation visit was conducted in response to allegations that the facility does not ensure residents have meals in a designated dining area with other residents and does not ensure planned social activities are available for residents in care.

The investigation found both allegations to be unfounded due to compliance with COVID-19 mitigation protocols, including temporary suspension of communal dining and social activities as recommended by Local Public Health authorities. No deficiencies were cited.

The complaint was investigated and found to be unfounded, meaning the allegations lacked reasonable basis. The complaint was dismissed.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2021-01-14 regarding inadequate resident care including hygiene assistance, clean clothing, and timely medication administration.

The investigation substantiated allegations that staff failed to assist residents with hygiene needs, ensure residents had clean clothing, and left residents in soiled clothing for extended periods due to insufficient staffing. Other allegations related to medication administration, response to authorized representatives, facility cleanliness, and safety were unsubstantiated.

The complaint investigation was substantiated for allegations related to failure to assist residents with hygiene needs, failure to ensure residents had clean clothing, and residents being left in soiled clothing for extended periods. The allegations related to medication administration, response to authorized representatives, facility cleanliness, and safe environment were unsubstantiated.

The visit was an unannounced case management visit conducted while at the facility for another reason.

No deficiencies were cited during the visit. The executive director confirmed that a former staff member was no longer employed at the facility.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 2021-08-02 regarding inadequate cleaning and care practices at the facility.

The investigation substantiated that staff failed to clean resident R3's room, posing a potential health and safety risk. Other allegations regarding residents left in soiled diapers, lack of showers, and feces on carpet were unsubstantiated due to insufficient evidence.

The complaint investigation was triggered by allegations including staff not cleaning residents' rooms, residents left in soiled diapers for extended periods, residents not receiving showers, and feces found on a resident's carpet. The allegation of uncleaned rooms was substantiated, while the others were unsubstantiated.

The inspection visit was an unannounced complaint investigation triggered by allegations received on 2021-03-04 regarding resident falls, medication mismanagement, and unequal treatment of residents.

The investigation found no preponderance of evidence to substantiate the allegations. Records showed a resident fall incident but no medication errors or unequal treatment were confirmed. The allegations were determined to be unsubstantiated.

The complaint involved allegations that a resident sustained multiple falls resulting in injuries, staff were mismanaging residents' medication, and staff were not treating residents equally. The investigation reviewed incident reports, medication administration records, care plans, and conducted interviews. The findings were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-03-25 regarding staff not answering residents' call pendents in a timely manner and other related complaints.

The investigation substantiated that staff failed to respond to residents R1 and R2's pendant calls in a timely manner, with 21 calls responded to after more than 30 minutes. Other allegations including insufficient staffing, medication administration, incontinence care, dignity, and meal delivery were unsubstantiated based on interviews and record reviews.

The complaint investigation was substantiated for the allegation that staff do not answer residents' call pendents in a timely manner. Other allegations including insufficient staff, untimely medication dispensing, unmet incontinence needs, lack of dignity in treatment, and untimely meal provision were unsubstantiated.

An unannounced complaint investigation was conducted due to an allegation of insufficient number of competent facility personnel present at all times to meet resident needs.

The investigation substantiated the allegation that a medication technician was assigned two medication carts to pass medications due to short staffing, posing a potential health and safety risk to residents.

The complaint was substantiated based on record reviews and interviews confirming short staffing and medication administration issues.

The visit was conducted to follow up on a self-reported theft incident that occurred on 12/21/2022 and another theft incident on 12/27/2022 involving residents' credit/debit cards.

The facility is investigating two theft incidents involving residents' credit/debit cards totaling approximately $6,700, with police reports filed and incident reports submitted to the licensing division.

The visit was complaint-related, following up on theft incidents reported by residents' family members. The incidents are under internal investigation and police involvement.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/19/2022 regarding staff mishandling a resident's medication and failure to seek timely medical attention for a resident.

Both allegations were substantiated. Staff administered a double dose of a discontinued medication to a resident for 14 days due to failure to update the medication system. Additionally, staff failed to seek timely medical attention for the resident after the medication error was discovered.

The complaint investigation was substantiated. The medication error involved a double dose administered for 14 days due to system update failure. Staff did not seek timely medical attention for the resident after the error was discovered. The Executive Director confirmed the findings and staff notified the hospice nurse and resident's family accordingly.

The visit was a case management investigation triggered by records indicating that facility staff assisted a resident in self-administering Morphine without hospice authorization, which was against the resident's Hospice Care Plan instructions.

A deficiency was cited for failure to comply with hospice care plan requirements, specifically for assisting a resident with Morphine administration without hospice direction, posing a potential health and safety risk.

Investigation found that staff assisted resident R1 with Morphine from 5/17/22 to 5/21/22 despite hospice care plan stating 'Do not use until directed by hospice'.

Unannounced complaint investigation visit conducted in response to allegations received on 06/01/2022 regarding timely medical attention, resident care needs, and medication administration.

All allegations were investigated and found to be unsubstantiated based on records review and interviews. No deficiencies were cited, and the facility staff's actions were consistent with hospice care directives.

Allegations included failure to seek timely medical attention, resident care needs not being met, and untimely medication administration. All were found unsubstantiated after investigation.

The visit occurred for case management purposes and to discuss self-reported theft incidents involving two residents that occurred on 2022-09-07.

The report discussed two theft incidents involving residents' missing jewelry, with one item later found. Staff received retraining on safeguarding property and valuables. No deficiencies were cited during the visit.

The visit was an infection control annual inspection conducted to evaluate compliance with COVID-19 and Monkeypox infection control practices.

The facility was found to have an effective mitigation plan for COVID-19, adequate PPE supplies, proper cleaning protocols, and operational fire safety equipment. No deficiencies were cited during this visit.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-11-04 alleging that residents were not getting their needs met.

The allegation was substantiated based on interviews and record reviews which found the facility failed to meet residents' needs due to being short staffed, resulting in residents not being changed timely, not receiving food or medications on time, late wake-ups, and missed scheduled showers.

The complaint was substantiated. The investigation found that residents' needs were not met due to staffing shortages, confirmed by interviews with residents, authorized representatives, staff, and acknowledgment by the former Executive Director during a prior visit on 2020-11-10.

Unannounced complaint investigation visit conducted due to multiple allegations received on 2020-11-06 regarding inadequate care, insufficient staffing, lack of assistance with incontinence care, medication administration issues, and staff verbal abuse.

The investigation substantiated allegations of failure to provide basic services, insufficient staffing, lack of assistance with incontinence care, and improper medication administration, all posing potential health and safety risks to residents. The allegation of staff verbally abusing residents was unsubstantiated.

The complaint investigation was substantiated for allegations of failure to provide basic services, insufficient staffing, lack of assistance with incontinence care, and medication administration errors. The allegation of staff verbally abusing residents was unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-02-03 alleging the facility failed to meet residents' needs and did not adhere to COVID-19 infection control protocols.

The investigation substantiated the allegation that the facility failed to meet residents' needs due to short staffing, resulting in residents not being changed timely, not receiving food or medications on time, and other care deficiencies. The allegation regarding failure to adhere to COVID-19 infection control was unsubstantiated, with the facility found to be following appropriate infection control measures.

The complaint investigation was substantiated for failure to meet residents' needs due to short staffing, with concerns about timely changing, food, showers, and medication administration. The COVID-19 infection control allegation was unsubstantiated.

Unannounced complaint investigation visit conducted in response to allegations including a resident sustaining a fractured back, staff not seeking timely medical attention, and staff not assisting residents with activities of daily living (ADLs) in a timely manner.

The investigation substantiated three allegations: a resident sustained a fractured back due to improper use of a Hoyer lift by untrained staff; staff did not seek timely medical attention for the injured resident; and staff did not assist residents with ADLs in a timely manner due to insufficient staffing. One allegation regarding failure to report the incident to licensing was found unfounded.

The complaint investigation was substantiated with findings that a resident sustained a lumbar spinal compression fracture due to improper use of a Hoyer lift by untrained staff, staff delayed seeking medical attention for the resident by two days, and staff failed to assist residents with ADLs in a timely manner due to insufficient staffing. One allegation that the incident was not reported to licensing was unfounded.

The inspection was an infection control annual inspection conducted to evaluate COVID-19 mitigation practices and overall infection control compliance at the facility.

The facility was found to have effective COVID-19 infection control measures in place, including staff training, vaccination of residents and staff, proper PPE usage, and social distancing. No deficiencies were cited during the visit.

The visit was an unannounced Case Management inspection conducted by Licensing Program Analyst G. Luk to evaluate compliance with licensing requirements.

A deficiency was observed where a staff member (S1) was fingerprint cleared but not associated with the facility, which violates California Code of Regulations, Title 22, posing an immediate health and safety risk.

The inspection was conducted as a health and safety check via tele-visit following receipt of a priority 1 complaint during the COVID-19 shelter in place order.

During the health and safety check, no deficiencies were cited and residents appeared safe with no imminent health or safety concerns observed.

The visit was triggered by a priority 1 complaint during the COVID-19 shelter in place order. No deficiencies were found and the complaint was effectively unsubstantiated based on the findings.