312700042-5-11-2023-25-AS-MSEY-CRVPVV-20230516113944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 05/11/2023
Date Signed: 05/11/2023 02:46:29 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
01/19/2023 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230119123543

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	312700042
ADMINISTRATOR:	MARK MORRIS		FACILITY TYPE:	740
ADDRESS:	567 3RD STREET		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	132	CENSUS:	DATE:	05/11/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Mark Morris		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident is being inappropriately restrained while in care
Resident was not properly assessed before residing in the facility
Staff are not providing access to a resident's personal belongings

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday May 11, 2023 to complete and deliver findings to a complaint received on 1/19/2023. LPA met with Administrator Mark and explained purpose of visit.

LPA interviewed the Administrator and facility staff including Business Office Manager, Receptionist, Nurses, and caregivers. LPA reviewed resident’s file including physicians report, assessment, care plan, and power of attorney paperwork. The results of the investigation is as follows:

R1 moved into the facility on January 7, 2023. In R1’s file, the personal service plan assessment was completed by an LVN and dated 1/7/2023. The assessment detailed that staff would be responsible for monitoring R1’s behaviors including aggression, agitation, and exit seeking. Per the assessment, the facility would also be responsible for the following care: status checks, redirecting, bathing, grooming reminders, toileting, laundry, and medication management. R1’s physicians report states that R1 has a

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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 2

Control Number 25-AS-20230119123543

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 312700042
	VISIT DATE: 05/11/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

primary diagnosis of Parkinson’s Disease with a secondary diagnosis of Dementia. R1 is not able to leave the facility unassisted. Staff interviews acknowledged that R1 followed a friend out of the facility, as they were leaving, but was able to be redirected back inside of the facility. Interviews with staff revealed that R1 required redirecting but was generally complaint. Additionally, interviews with staff revealed that R1’s family member was asking several staff for copies of R1’s file and power of attorney paperwork. All staff stated that they informed the family member that they were unable to release this information without consent of the power of attorney. Staff interviewed stated that R1 never asked for this paperwork.

Based on information obtained, LPA finds the allegations to be UNFOUNDED- means that the allegations are false, could not have happened, and/or are without a reasonable basis.

Exit interview. A copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2