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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 10/10/2023
Date Signed: 10/10/2023 02:10:29 PM

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
04/06/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230406113411
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: 70DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mark MorrisTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not meet resident's hygiene needs.
Unqualified staff administered insulin shots to residents.
Staff falsified residents' medication records.
Resident sustained an unwitnessed fall resulting in a fracture.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday October 10, 2023, to complete and deliver findings to a complaint received on 4/6/2023. LPA met with Administrator Mark and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, current and previous staff. LPA interviewed R1’s POA regarding the allegations. LPA reviewed R1’s file at the facility including physicians report, nursing notes, MARs, hospital discharge paperwork, physician’s orders, and employee notes regarding R1’s POA behavior to staff. The result of the investigation is as follows:

Per staff interviews, S1 worked as the resident services director. At this time, the facility scheduled nurses for 12-hour shifts. Per interviews, there were no nurses scheduled for 7 days per week. According to the allegation, S1 would conduct blood sugar checks and give R2 their insulin. S2, who is a registered nurse, would then sign the MAR. According to State records, S1 obtained their nursing license on 7/14/2022.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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 59-AS-20230406113411
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: 10/10/2023
NARRATIVE
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Previous staff interviews acknowledge witnessing S1 provide insulin injections prior to obtaining their license.

Interviews from previous and current staff acknowledged that R1 needed assistance with bathing, dressing, grooming, and incontinence care. Interviews stated that R1’s was incontinent of bladder and bowel. Staff stated that, for most of R1’s stay at the facility, R1’s POA refused to provide proper incontinence products for R1. Therefore, when R1 would become incontinent, this required a change of clothing. Additionally, staff stated that it was difficult for R1 to comply with incontinence care. Nursing notes also detail R1’s refusal for showers.

Interviews and nursing notes detail repeated times where R1 was observed walking without their walker. Nursing notes also detail staff attempts to have R1 use their walker. Nursing notes also detailed R1 would refuse to use their glasses or leave them in other resident apartments. R1’s physicians report indicated that they had motor impairment/paralysis and needed to use a walker to prevent falls. Additionally, R1 had a history of seizures which led to additional falls. Therefore, due to R1’s history of seizures and falls, along with wandering behavior, the facility failed to provide proper supervision. Additionally, R1’s care plan was not updated as required based on level of care.


Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is 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: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20230406113411
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: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2023
Section Cited
CCR
87705(c)(4)
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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety. . .
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Administrator to submit plan regarding 1:1 and eviction procedures for residents who require additonal care and supervision outside of normal staffing.
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This requirement was not met as evidenced by R1 having a Dx of seizures and having repeated falls and wandering. This poses a direct threat to the health and safety of residents in care.
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Type A
10/11/2023
Section Cited
CCR
87629(b)(1)
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87629 Injections
(b) . . . the licensees who admit or retain residents who require injections shall be responsible for the following:
(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require
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Administrator to submit nursing schedule including back-up plan if schedule nurse calls off.
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assistance. This requirement was not met as evidenced by allowing an employee who did not have their nursing license administer insulin injections. This poses a direct threat to the health and safety of residents 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: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
04/06/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230406113411

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: 70DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mark MorrisTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not maintain facility is a clean and sanitary manner.
Resident was harassed by another resident while in care.
Staff left resident in urine and feces soiled sheets.
Staff did not ensure that resident was adequately hydrated while in care.
Staff did not give resident prescribed medication.
Facility did not have sufficient staff to meet the needs of the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday October 10, 2023, to complete and deliver findings to a complaint received on 4/6/2023. LPA met with Administrator Mark and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, current and previous staff. LPA interviewed R1’s POA regarding the allegations. LPA reviewed R1’s file at the facility including physicians report, nursing notes, MARs, hospital discharge paperwork, physician’s orders, and employee notes regarding R1’s POA behavior to staff. The result of the investigation is as follows:

Staff interviews revealed that R1 would, at times, refuse toileting and showers. They would also take off their brief when in bed. Interviews acknowledged repeated attempts to assist R1 after they would refuse care. Interviews did not reveal that R1 was left in soiled sheets.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20230406113411
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: 10/10/2023
NARRATIVE
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LPA reviewed R1’s MARs. Additionally, based on staff interviews and documentation review, LPA learned that R1 would often refuse medication. LPA reviewed communication between the facility and R1's primary physician. Nursing notes stated that R1 would become aggressive and refuse to take their medication.

LPA interviewed previous and current staff who stated that R1’s had a history of agitation and being aggressive. R1 would constantly walk the hallways of the facility. LPA reviewed R1’s nursing notes which detail, at times, R1 was exit seeking. R1 had a history of going in other resident apartments and taking their items. No staff interviews revealed that R1 was being harassed by another resident. R1 had several roommates while living at the facility. Interviews acknowledged that, due to cognitive impairment of the residents, R1 and their roommate would create messes in the room. Staff stated that they tried to keep resident items organized and belongings separated.

Staff interviews stated that throughout R1’s stay at the facility, there were times when the facility was short of staff due to call-ins. LPA was unable to obtain staffing schedules due to the amount of time that had passed and management turnover.

Staff interviews stated that R1 was offered hydration at meals, and in between meals. Additionally, R1 had a hydration bottle. Per staff interviews, R1 would often leave the hydration bottle while walking the hallways, pour the water out, or refuse to drink. Interviews stated that R1 was constantly walking the hallways. At times, it was difficult to get R1 to sit.

Based on information obtained during the investigation, LPA finds the 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 evidence to prove that the alleged violation occurred,

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

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230406113411
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: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence
(b) . . .the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met
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Administrator to submit proof of training regarding incontinence care and cleanliness.
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as evidenced by R1 having repeated incontinence in clothing documented by nursing notes and photographs. This poses an indirect threat to the health and safety of residents in care.
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Type B
10/27/2023
Section Cited
CCR
87207
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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement was not met as evidenced by S2 signing the MAR regarding R2's insulin
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Administrator to submit proof of training for care staff regarding documentation.
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when they were not the one to administer the injection. This poses an indirect threat to the health and safety of residents 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: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6