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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:42:33 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2021 and conducted by Evaluator Melissa Lusby
COMPLAINT CONTROL NUMBER: 25-AS-20210604124030
FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:BOYLE, SABRINAFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: 58DATE:
06/16/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Zahra SamirTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Facility is not responding to pendants in a timely manner
INVESTIGATION FINDINGS:
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13
LPA Lusby arrived on Wednesday June 16, 2021 to conclude the investigation regarding the above allegations. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. LPA was screened by the front desk prior to entry.

Throughout the course of the investigation, LPA reviewed R1's physicians report, nursing notes, and service plan. LPA also conducted relevant party interviews. The Department notes that while pressing the pendant firmly twice does cancel the pendant, all parties interviewed acknowledged that through staff communication, staff members check to ensure resident's needs are met.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2021 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210604124030

FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:BOYLE, SABRINAFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: 58DATE:
06/16/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Zahra SamirTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is not being provided with water leading to UTI/hospitalization
INVESTIGATION FINDINGS:
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3
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5
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7
8
9
10
11
12
13
LPA Lusby arrived on Wednesday June 16, 2021 to conclude the investigation regarding the above allegations. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. LPA was screened by the front desk prior to entry. Throughout the course of the investigation, LPA reviewed R1's physicians report, nursing notes, and service plan. LPA also conducted relevant party interviews. Based on the information obtained, the Department has concluded that the above allegation is unfounded.An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. LPA Lusby conducted an exit interview. A copy of this report was left at the facility.
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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 3
Control Number 25-AS-20210604124030
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
VISIT DATE: 06/16/2021
NARRATIVE
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The Department finds the above allegation to be UNSUBSTANTIATED. A finding that the complaint allegation 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 violations occurred.

Appeal rights were printed and given. An exit interview was conducted. A copy of this report was left the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3