<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 07/23/2026
Date Signed: 07/23/2026 03:05:33 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
07/08/2026 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260708103639
FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:MEGAN GALLAGHERFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: 64DATE:
07/23/2026
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sabrina Boyle and Maybeth ChaceTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not dispense medications as prescribed
Staff did not seek medical attention for resident in a timely manner
unqualified staff performed a restricted health procedure
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday July 23, 2026, unannounced to conduct a complaint visit regarding the above allegations. LPA met with Sabrina Boyle and Maybeth Chace and explained the purpose of the visit.

LPA interviewed staff regarding the allegations. LPA learned the following: On July 7, 2026, staff who is a new med tech (S1), was administering medications. S1 provided R1 with the medication Glipizide 20 mg which belonged to another resident. S1 then informed the nurse on duty (N1) of the error. S1 and N1 then contacted the facility Administrator for guidance. Per the facility Administrator, they were to monitor the resident and conduct hourly blood sugar checks. N1 conducted blood sugar checks until the end of their shift at 8pm. Then, S1, who is not a skilled professional, was instructed to conduct the blood sugar checks. S1 and other med techs at the facility were unable to obtain a blood sugar reading. According to staff interviews, S1 became weak and did not respond to their name when checked around 9:20pm. The
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
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 5
Control Number 59-AS-20260708103639
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: 07/23/2026
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
26
27
28
29
30
31
32
NOC shift began at 10pm, staff observed R1 to be sweating and unresponsive. S2, who works as a NOC shift caregiver at the facility, is also a certified phlebotomist, obtained a blood sugar of 34. 911 was then called around 10:40pm for the resident to be sent to the hospital for evaluation.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegations are substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency cited on 9099-D. Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20260708103639
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: 07/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2026
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. . . .
(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met
1
2
3
4
5
6
7
Facility to submit plan regarding retraining med techs.
8
9
10
11
12
13
14
as evidenced by R1 being provided and consuming the medication for another resident. This poses a direct threat to the health and safety of residents in care.
8
9
10
11
12
13
14
Type A
07/24/2026
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. . . .(5) Facility staff, except those authorized by law, shall not administer injections . . .this requirement
1
2
3
4
5
6
7
Facility to submit inservice training to LPA regarding protocol and procedures for blood sugar checks.
8
9
10
11
12
13
14
was not met as evidenced by med techs performing finger sticks for blood sugar checks. This poses a direct threat to the health and safety of residents in care.
8
9
10
11
12
13
14
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: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20260708103639
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: 07/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2026
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis . . this requirement was not
1
2
3
4
5
6
7
Facility to submit plan to retrain all staff regarding policy on calling 911 in the event of an emergency.
8
9
10
11
12
13
14
met as evidenced by staff not calling 911 once they began to have a serious change in condition. This poses a direct threat to the health and safety of residents in care.
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: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
07/08/2026 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260708103639

FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:MEGAN GALLAGHERFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE:CAZIP CODE:
95648
CAPACITY:132CENSUS: 64DATE:
07/23/2026
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sabrina Boyle and Maybeth ChaceTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure reporting requirements were followed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday July 23, 2026, unannounced to conduct a complaint visit regarding the above allegation. LPA met with Sabrina Boyle and Maybeth Chace and explained the purpose of the visit.

According to staff interviews and documentation, R1’s POA and primary physician were notified of the medication error and subsequent hospitalization. Based on information obtained during the investigation, LPA finds the allegation 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 evidence to prove that the alleged violation occurred.

Exit interview. A copy of this report was provided to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5