312700042-4-16-2021-27-AS-KHOS-C2BKAZ-20210422074445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 04/16/2021
Date Signed: 04/16/2021 02:25:41 PM

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
08/05/2020 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200805095859

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	312700042
ADMINISTRATOR:	BOYLE, SABRINA		FACILITY TYPE:	740
ADDRESS:	567 3RD STREET		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	132	CENSUS: 59	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Zahra Samir, Assistant Executive Director		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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9

Staff are not providing food to resident(s) on a timely basis
Staff are not administering medication to resident according to physicians instructions

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Melissa Lusby contacted the facility via telephone to conclude a complaint investigation on 4/16/2021 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the complaint with Assistant Executive Director Zahra Samir.Throughout the investigation, LPA interviewed staff, resident notes, and R1's service plan, MAR, medication list, and admission agreement. Based on information obtained, LPA finds the above allegations to be UNSUBSTANTIATED- A finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. Appeal rights were printed and given to Administrator. This report was emailed to the Administrator to review, sign and send back. A copy of the signed report will be stored in the facility file.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

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

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
08/05/2020 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200805095859

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	312700042
ADMINISTRATOR:	BOYLE, SABRINA		FACILITY TYPE:	740
ADDRESS:	567 3RD STREET		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	132	CENSUS: 59	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Zahra Samir, Assistant Executive Director		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's apartment is unsanitary
Staff do not provide activities for residents

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Melissa Lusby contacted the facility via telephone to conclude a complaint investigation on 4/162021 due to COVID-19 and pre-cautionary measures. LPA discussed the purpose of the call and the elements of the complaint with Administrator Executive Director Zahra Samir. Throughout the course of the investigation, LPA Lusby interviewed staff, reviewed resident notes, activity calendars, maintenance logs, admission agreement, and service plan. Based on LPAs interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. A copy of this report was emailed to the Administrator to review, sign and send back. The signed report will be stored in the facility file.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 2