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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 09:21:24 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
01/11/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20230111151017
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:
01:00 PM
MET WITH:Mark MorrisTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility did not safeguard resident belongings
Facility staff physically abused resident in care
Facility failed to report
Resident was not given medication as prescribed
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 1/11/2023. LPA met with Administrator Mark and explained purpose of visit.

Throughout the course of the investigation, LPA interviewed the Administrator, Business Office Director, previous memory care director, current and previous staff. LPA reviewed R1’s file at the facility including physicians report, progress notes, MARs from March – December 2022, LIC621, LIC500, personal service plan, preplacement appraisal and medication orders and communication with physicians. The result of the investigation is as follows:

LPA interviewed Business Office Director who stated that on 12/7/2022, it was reported to the Memory Care Director, at the time, that S1 witnessed S2 hitting R1. While S2 was being interviewed, they acknowledged that they grabbed R1’s hands and held them down. S2 suspended and later terminated. The facility acknowledged that there was not a SOC341
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-20230111151017
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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and/or LIC624 completed and sent to the appropriate agencies.

LPA reviewed all Medication Administration Records while the R1 resided at the facility. LPA also reviewed all orders for R1 regarding the medication Seroquel. LPA observed 10 signed orders for this medication. LPA observed that the medication orders in the MAR matched the signed orders. However, there were no signatures for this medication on the following dates 9/6, 9/8, 9/21, 9/22, 9/23, 9/27, 10/6, 10/14, 10/30, 10/26, 11/4 (twice), 11/8, 11/10, 11/16. There were no records indicating a reason as to why the medication was not given.

The Administrator acknowledged that R1’s prescription glasses and lower dentures were missing. Per the Administrator, he asked R1’s family to provide two estimates to replace the missing denture. However, R1’s family only produced one estimate approximately $8,000.

Based on the information detailed above, LPA finds the 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.

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: 2 of 6
Control Number 25-AS-20230111151017
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
06/16/2023
Section Cited
HSC
87468.1(a)(3)
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Personal Rights of Residents in All Facilities
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This
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Administrator agrees submit proof scheduled training regarding resident rights for staff.
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requirement was not met as evidence by S2 forcefully grabbing R1's hands while performing ADLs. This poses an immediate risk to the health and safety of resident in care.
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Type A
06/16/2023
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care
The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:based on interview and MAR document review, resident was not
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Administrator to schedule a training regarding medication requirements.
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given medication as prescribed. 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: 3 of 6
Control Number 25-AS-20230111151017
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
06/16/2023
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports . . (1) A written report shall be submitted to the licensing agency at (D) Any incident which threatens the welfare, safety or health of any resident . . .
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Administrator to schedule training with management regarding reporting requirements.
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This requirement was not met as evidnced by no SOC341 or LIC624 submitted to the Ombudsman or Licensing. This poses a potential risk to the health and safety of resident in care.
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Type B
06/29/2023
Section Cited
CCR
87218(a)(2)
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Theft and Loss
(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. . . This requirement was not met as evidenced by R1's glasses and lower dentures were
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Administrator agreed to work with the family to come to an agreement regarding replacing dentures while there is an open balance of over $5,000 on R1's account.
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lost and R1's POA has not received reimbursement for the items. This poses a potential 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: 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
01/11/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20230111151017

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:
01:00 PM
MET WITH:Mark MorrisTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility 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 1/11/2023. LPA met with Administrator Mark and explained purpose of visit.

Throughout the course of the investigation, LPA interviewed the Administrator, Business Office Director, previous memory care director, current and previous staff. LPA reviewed R1’s file at the facility including physicians report, progress notes, MARs from March – December 2022, LIC621, LIC500, personal service plan, preplacement appraisal and medication orders and communication with physicians. The result of the investigation is as follows:

LPA reviewed progress notes which detail R1 exhibiting behaviors such as refusing medication, aggressiveness with staff and residents, exit seeking, and agitation. These behaviors were exhibited throughout R1’s stay at the facility. LPA reviewed a printout from Sutter Health with handwritten note
Unsubstantiated
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-20230111151017
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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‘collected and taken by family to the lab’ dated 11/5/2022. However, progress notes and interviews conducted did not reveal R1 exhibited symptoms of a UTI that went untreated.

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.
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