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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700042
Report Date: 03/24/2022
Date Signed: 03/25/2022 08:54:20 AM


Document Has Been Signed on 03/25/2022 08:54 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
312700042
ADMINISTRATOR:JO ANN FRANKLINFACILITY TYPE:
740
ADDRESS:567 3RD STREETTELEPHONE:
(916) 409-4150
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:132CENSUS: 60DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mark Morris, Maintenance DirectorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Williams arrived on Thursday March 24, 2022 to conduct the annual inspection. 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 he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Maintenance Director, Mark Morris, toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: kitchen, outdoor patio, laundry rooms, bedrooms (4) and bathrooms (5). In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and Maintenance Director completed the infection control domain together and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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