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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700042
Report Date: 02/06/2024
Date Signed: 02/06/2024 11:46:52 AM


Document Has Been Signed on 02/06/2024 11:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:MARK MORRISFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: 67DATE:
02/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Emily Pinedo, Resident Services DirectorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday February 6, 2024, to conduct a case management visit to obtain additional information on an incident which was reported to the Department on Wednesday January 31, 2024.

LPA discussed the incident with Resident Services Director Emily. LPA learned that on Saturday January 27, 2024, R1 was observed to be in distress at approximately 4:20 pm. Emily observed resident attempting to clear their throat. A short time later, Emily began the Heimlich Maneuver until first responders arrived at the facility. R1 was pronounced deceased at the facility at approximately 4:57pm.

LPA obtained the following documents from R1's file: physicians report, preplacement appraisal, care plan, diet clarification form, identification and emergency information form, and current service plan. Per documents, R1 was independent with meals and not on a special diet.

No deficiencies cited. Exit interview conducted. 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: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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