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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 06/15/2023
Date Signed: 06/16/2023 09:16:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221122121630
FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:MARK MORRISFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: 69DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mark MorrisTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff did not properly monitor resident's catheter
Facility staff are not properly supervising residents who may be a fall risk
Facility staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday June 15, 2023, to complete and deliver findings to a complaint received on 11/22/2022. LPA met with Administrator Mark and explained purpose of visit.

Throughout the course of the investigation, LPA interviewed staff including the Administrator, nurses, med techs, and caregivers. LPA reviewed R1’s file at the facility including physicians report, progress notes, MARS (September, October, November), and a record of falls. Additionally, LPA interviewed R1’s home health company which provided skilled care for R1’s catheter. The result of the investigation is as follows:

Based on notes on R1’s MAR, they were out of the facility for the following times: Sept 20 – 21, Oct 13 – Oct 22, Oct 31 – Nov 1, Nov 4 – Nov 5, Nov 9 – Nov 10, and Nov 12 – Nov 22. Additionally, based on progress notes and documented faxes to R1’s primary physicians, R1 fell on the following
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
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 6
Control Number 25-AS-20221122121630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 312700042
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2023
Section Cited
CCR
87466
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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical. . . . the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible
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Facility to begin training for all staff regarding observation of resident requirements. Facility to complete by send LPA proof of training by end of day 6/19/2023.
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person. This requirement was not met as evidenced by R1's POA and doctor not being notified of their catheter not draining. This poses an immediate risk to the health and safety of residents in care.
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Type A
06/16/2023
Section Cited
HSC
1569.312(e)
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Basic services requirements
(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by R1 sustaining multiple falls.
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Administrator agreed to submit a memo of understading regarding upholding the admission agreement by implementing a 1:1 when a resident is a danger to themselves or someone else.
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This poses a direct risk to the health and safety of resident in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20221122121630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 312700042
VISIT DATE: 06/15/2023
NARRATIVE
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dates: 10/2, 10/6, 10/9, 10/13, 10/24, 11/5, and 11/9. R1’s fall on 11/9, resulted in a fractured shoulder and laceration on their head. Progress notes on 10/31, state that there was no catheter output for all of NOC shift. There is no documentation that R1’s family or physician was notified. R1 was later sent to the hospital where their hospital records note that more than 854 mL was drained.

R1 was followed by Freedom Home Health, who had provided them with regular nurse visits. While the facility was responsible for draining the catheter, any medical interventions related to the catheter was provided by Freedom Home Health. However, because a catheter is considered a restricted health condition, the facility was required to provide training for all staff regarding R1 and their catheter care. There is no documented evidence that the facility staff were provided this training.

Based on the information detailed above, LPA finds that both these allegations are substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Due to R1's fall which resulted in a fractured shoulder, a $500 civil penalty for serious bodily injury will be issued. This civil penalty will be issued at a later date due to technical issues.

Deficiencies cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 25-AS-20221122121630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 312700042
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2023
Section Cited
CCR
87623
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87623 Indwelling Urinary Catheter
(B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed.

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The administrator agreed to submit a memo of understanding regarding the regulation.
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This requirement was not met as evidenced by no documentation of staff training related to R1 and their catheter care. This poses an indirect threat to the health and safety of resident in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221122121630

FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:MARK MORRISFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: 69DATE:
06/15/2023
ANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mark MorrisTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
An appropriately skilled professional is not providing assistance resident with a catheter
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday June 15, 2023, to complete and deliver findings to a complaint received on 11/22/2022. LPA met with Administrator Mark and explained purpose of visit.

Throughout the course of the investigation, LPA interviewed staff including the Administrator, nurses, med techs, and caregivers. LPA reviewed R1’s file at the facility including physicians report, progress notes, MARS (September, October, November), and a record of falls. Additionally, LPA interviewed R1’s home health company which provided skilled care for R1’s catheter. The result of the investigation is as follows:

R1 was provided home health services for their catheter care while residing at the facility. Per the Director of Nursing at Freedom Home Health, their agency conducted 9 visits. These visits were provided by RNs who performed irrigation and other skilled procedures. The staff at the facility were responsible for monitoring the catheter and draining.
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20221122121630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 312700042
VISIT DATE: 06/15/2023
NARRATIVE
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Based on LPAs interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6