312700555-2-16-2021-27-AS-KHOS-BYBS5J-20210217123425

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700555
Report Date: 02/16/2021
Date Signed: 02/16/2021 03:34:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2020 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200430161633

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING		FACILITY NUMBER:	312700555
ADMINISTRATOR:	BOYLE, SABRINA		FACILITY TYPE:	740
ADDRESS:	550 2ND ST		TELEPHONE:	(916) 409-4150
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	162	CENSUS: 56	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Sabrina Boyle		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
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9

Resident left unattended by staff during an emergency

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Lusby contacted the facility via telephone to conclude a complaint investigation on 2/16/2021 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the complaint with Sabrina Boyle. LPA Lusby interviewed Administrator Sabrina Boyle and various staff, and reviewed staff training. LPA reviewed R1's physicians report, care plan, hospital discharge paperwork, and nursing notes. Based on information obtained, LPA finds the above allegation to be UNSUBSTANTIATED- A finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. Appeal rights were printed and given to Administrator. A copy of this report was emailed to the Administrator to review, sign and send back.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

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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