312700042-3-9-2022-25-AS-APEZ-CCJNTD-20220315104432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700042
Report Date: 03/09/2022
Date Signed: 03/09/2022 02:58:52 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
03/02/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220302094927

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	312700042
ADMINISTRATOR:	JO ANN FRANKLIN		FACILITY TYPE:	740
ADDRESS:	567 3RD STREET		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	132	CENSUS: 67	DATE:	03/09/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jo Ann Franklin- Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is not following proper COVID-19 mask guidance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 3/9/2022 to conduct a Complaint Investigation. LPA met with Executive Director (ED), Jo Ann Franklin, and explained the purpose of the visit. Prior to initiating the complaint inspection, 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 they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA observed five (5) staff working in the facilirt at time of visit. Of those staff, neither were wearing masks. PIN 20-22-ASC issued on 2/7/2022 states All ASC residential facilities must strictly adhere to current CDPH Masking Gudiance:

Masks are required for all individuals in the following indoor setting regardless of vaccination status:
Long Term Care Settings & Adult and Senior Care Facilities.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220302094927

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: 03/09/2022

NARRATIVE

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Based on information obtained, the Department finds the portion of the allegation pertaining to clients to be SUBSTANTIATED. - A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Based on California Code of Regulation, Title 22, Division & Chapter 8, one (1) deficiency is being cited.

Appeal Rights provided.

Exit interview conducted with ED.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20220302094927

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: 03/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/16/2022 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Executive Director agrees to conduct in- service for all staff. ED is to review PIN 20-22-ASC and submit to CCL in writing that PIN was reviewed. Proof of in-service and review of PIN is to be submitted by POC due date, 3/16/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation of staff, the facility staff are not wearing masks while inside of the facility, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
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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: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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