312700042-8-23-2022-25-AS-KHOS-CHSKUS-20220830081313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 08/23/2022
Date Signed: 08/23/2022 10:51:16 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220307105102

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	312700042
ADMINISTRATOR:	JO ANN FRANKLIN		FACILITY TYPE:	740
ADDRESS:	567 3RD STREET		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	132	CENSUS: 75	DATE:	08/23/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director- Mark Morris		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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- Blood sugar checks are being administered by someone who is not a skilled professional.
- G-Tube feedings are being administered by someone who is not a skilled professional.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 08/23/2022 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 03/07/2022. LPA met with Administrator, Mark Morris, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

Throughout the course of the complaint investigation, the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, needs and services plan, emergency contact, G-Tube doctor’s order, and approved exception request for prohibited health condition from the Department.

Continue on page LIC-9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

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 25-AS-20220307105102

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 312700042
	VISIT DATE: 08/23/2022

NARRATIVE

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Allegation: Blood sugar checks are being administered by someone who is not a skilled professional. – Unsubstantiated.

According to Complainant, an unlicensed nursing student working at the facility as a Resident Care Director (RCD) is assisting R1 with blood sugar checks. Interview statement received from Memory Care Director, Denise Landgraf, indicated there are a total of four (4) residents on insulin and one (1) resident that needs assistance with blood sugar checks. MCD stated only nurses are assisting residents with blood sugar checks. MCD stated she started working at the facility on 06/01/2022 and, shortly after, RCD got licensed and was officially a nurse. Interview statement from ED indicated that, during the time the complaint was opened, RCD was a student nurse and working while Sabrina Boyle was the ED. ED was also working at the facility at the time Sabrina Boyle was the ED. ED stated he observed RCD shadowing Sabrina Boyle but was not performing any blood sugar checks on residents. Interview statement received from staff member (S1) indicated that S1 has not observed RCD assisting residents with blood sugar checks. Interview statement received from staff member (S2) revealed that S2 had observed RCD assisting a resident with blood sugar checks. S2 indicated that RCD is a nurse and is allowed to assist with blood sugar checks. On 03/09/2022, LPA interviewed RCD, who denied assisting a resident with blood sugar checks. RCD also denied being a Licensed Vocational Nurse at the time of the interview. According to Board of Vocational Nursing and Psychiatric Technicians DCA search, RCD is a Licensed Vocational Nurse with an issuance date of 07/14/2022.

Allegation: G-Tube feedings are being administered by someone who is not a skilled professional. – Unsubstantiated.

According to Complainant, Resident Care Director (RCD) who is a nursing student without a license is assisting R1 with G-Tube feedings. R1’s physician report states R1’s primary diagnosis is diabetes. R1 has a Laryngectomy tube. On 03/29/2022, the Department had granted an exception request for the prohibited health condition of G-Tube care for R1. Terms and conditions include: the licensee will monitor, document, and ensure that all routine feeding, hydration, medication administration through the G-Tube and stoma cleaning are provided by a licensed skilled professional due to the resident's inability to perform tasks on their own.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220307105102

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 312700042
	VISIT DATE: 08/23/2022

NARRATIVE

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The licensee will ensure and document that staff responsible for the care of this resident will be trained by the licensed skilled professional for G-Tube feeding, hydration and stoma cleaning. For routine medications, staff will be trained by the skilled nursing professional per physician's orders as to administration procedure. This training is in addition to other required regulatory training and must be documented and maintained on file. The licensee will ensure that a skilled professional is maintaining oversight of all aspects of care for the G-Tube and training of staff assigned to this resident. Training shall be updated no less than once every 6 months. All training, procedures, protocols and other physician and skilled professional notes shall be maintained on file at the facility.

According to R1’s needs and services plan, R1 does not need assistance with Laryngectomy tube and self manages Laryngeal tube. R1 can suction and clean Laryngeal tube. Nursing staff will stand by as R1 cleans tube as ordered daily to make sure proper care is being done. Facility staff will monitor for signs and symptoms of infection or complications and notify medical doctor. Facility staff will observe and prompt R1 with Laryngeal tube care and suctioning.

The Department conducted interviews with a total of six (6) facility staff. Interview statements received from S1 and S2 were consistent with one another. S1 and S2 indicated that facility’s Licensed Vocational Nurses (LVNs) are the only ones to assist residents with prohibited health conditions, such as G-tube care. Interview statement received from MCD revealed that the facility always has a nurse working in the building. MCD stated that, if MCD is off and a nurse is not on-site or nowhere to be found in the community, the facility will call MCD to come in. MCD stated that, when they were hired for this position, management had gone over expectations with MCD. The management’s expectations are that MCD is to be on call and come to the facility when needed. Interview with ED revealed that there is always a nurse working in the building and, if there is ever a situation where there are no nurses in the building, the facility would use on-call nurses or have the nurse at the community next door (Summerset Lincoln Assisting Living) to assist. LPA interviewed RSD, who denied assisting resident with G-tube feeding.

Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted with Executive Director, copy of report was provided via email.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC9099 (FAS) - (06/04)

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