312700042-6-6-2023-25-AS-KHOS-CSYP3K-20230620105740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 06/06/2023
Date Signed: 06/06/2023 10:20:54 AM

Unsubstantiated

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
02/14/2023 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230214091816

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: 71	DATE:	06/06/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Mark Morris		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff failed to monitor resident's water and food intake resulting in hospitalization

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday June 6, 2023, to complete and deliver findings to a complaint received on 2/14/2023. LPA met with Administrator Mark and explained purpose of visit.

LPA interviewed the Administrator and facility staff including nurses, med techs, caregivers, and activity staff. Med tech (S1) acknowledged they contacted the physician and POA regarding R1’s decline. S2, S3, and S4 stated that they offered snacks and hydration to R1. LPA reviewed R1’s file including the physicians report and assessment. The physicians report which was signed by a physician on 1/6/2023, stated that R1 had the capacity to feed themselves. Additionally, the facility assessment dated 1/7/2023, stated that R1 was independent for meals and did not require meal reminders. Due to the information above, LPA finds the allegation 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 Administrator, copy of report was provided via email.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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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