312700042-5-20-2026-59-AS-MPAS-DU9N6R-20260520101133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700042
Report Date: 05/20/2026
Date Signed: 05/20/2026 10:11:37 AM

Document Has Been Signed on 05/20/2026 10:11 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 CARE		FACILITY NUMBER:	312700042
ADMINISTRATOR/ DIRECTOR:	MEGAN GALLAGHER		FACILITY TYPE:	740
ADDRESS:	567 3RD STREET		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY: 132		CENSUS: 66	DATE:	05/20/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Desiree Burns		TIME VISIT/ INSPECTION COMPLETED:	10:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 20, 2026 to conduct a case management visit on an incident which was reported to the Department on May 2, 2026. LPA met with interim Executive Director Desiree and explained the purpose of the visit. LPA and Desiree discussed R1's incident on 4/24/2026. R1 had a fall on 4/17/2026. This fall occurred because another resident opened a door, which caused R1 to fall. 911 was called and R1 was sent to Sutter ER for evaluation. ER discharged R1 with a diagnosis of injury of right shoulder, initial encounter. Xrays were conducted and no signs of broken bones. On 4/23/2026, R1's primary physician arrived at facility and assessed R1. This primary physician said that R1 did not need to wear a shoulder sling and advised the facility to monitor the resident and give Tylenol as needed. On 4/24/2026, staff observed R1's right hand was swollen with complaints of severe pain. R1 was transported back to Sutter ER where they were diagnosed with a closed displaced fracture of the humeral neck at the right shoulder. R1 returned to the facility with instructions to make a follow-up appointment with an orthopedic surgeon. On 4/27/2026, Desiree called to follow-up with the orthopedics office to try and schedule an appointment. Family then decided to place R1 on hospice services. R1 was admitted to hospice services on 4/29/2026. LPA obtained a copy of R1's physicians report, care plan, hospital discharge paperwork. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Melissa Parks
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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