312700042-4-16-2021-27-AS-KHOS-C2BJSH-20210422071821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 04/16/2021
Date Signed: 04/16/2021 01:26:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2020 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200703093902

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		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
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5
6
7
8
9

Facility is not properly storing medication

INVESTIGATION FINDINGS:

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2
3
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5
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7
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9
10
11
12
13

Licensing Program Analyst (LPA) Melissa Lusby contacted the facility via telephone to conclude a complaint investigation due to COVID-19 and pre-cautionary measures. LPA discussed the purpose of the call and the elements of the allegation with Assistant Executive Director Zahra Samir. During the course of the investigation, LPA Lusby reviewed R1's MAR, resident notes, and interviewed staff. As a result of this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. Appeal rights were printed and given to Assistant Executive Director. A copy of this report was emailed to Zahra to review, sign, and return. A signed copy of the report will be stored in facility file.

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2020 and conducted by Evaluator Melissa Lusby

COMPLAINT CONTROL NUMBER: 27-AS-20200703093902

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:	Sabrina Boyle		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not adequately trained
Staff are not responding to resident's needs in a timely manner

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 4/16/2021 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, reviewed new hire training and paperwork, resident notes, and R1's service plan. Based on information obtained, LPA finds the above allegations to be UNSUBSTANTIATED- A finding that the complaint is unsubstantiated means 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. 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: (916) 263-4700
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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2020 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200703093902

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		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is overmedicating Resident
Facility is not providing a safe environment due to repeated falls

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, R1's 602, admission agreement, service plan, and hospital discharge paperwork. 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: (916) 263-4700
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: 3 of 4

Control Number 27-AS-20200703093902

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 312700042
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/19/2021 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible . . .This requirement was not met as	1 2 3 4 5 6 7	Assistant Executive Director provided proof that responsible employee was disciplined.
	8 9 10 11 12 13 14	evidenced by staff interviews and resident notes acknowledging medication left in resident's room. This poses an immediate threat to the health and safety of the resident.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4