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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700042
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:11:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:ZAHRA SAMIRFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: 60DATE:
10/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Sabrina BoyleTIME COMPLETED:
03:30 PM
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LPA Lusby arrived on Friday October 21, 2021 to conduct a case management visit. 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 mask.

The purpose of this visit was to verify that S1 was no longer employed and no longer associated to the facility. Administrator Sabrina confirmed S1's termination on 10/19/2020 and that S1 has not been in the facility since.

No deficiency observed.

Exit interview conducted and a copy of the report was given.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa LusbyTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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