312700555-3-11-2024-59-AS-MSEY-D3BMCQ-20240313092953

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700555
Report Date: 03/11/2024
Date Signed: 03/11/2024 10:39:45 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/12/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240212120457

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING		FACILITY NUMBER:	312700555
ADMINISTRATOR:	ROUZBEH MORADHASEL		FACILITY TYPE:	740
ADDRESS:	550 2ND ST		TELEPHONE:	(916) 644-3151
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	162	CENSUS: 98	DATE:	03/11/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Rouzbeh Moradhasel		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff did not follow their emergency disaster plan

INVESTIGATION FINDINGS:

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LPA Parks arrived on Monday March 11, 2024, to conclude a complaint investigation regarding the above allegation. LPA met with Administrator Rouzbeh and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, facility staff and R1. LPA reviewed the generator’s test runs and the facility’s Emergency and Disaster Plan.

LPA learned that there was a city-wide power outage from Sunday February 11th until the evening of Monday February 12th. While the facility does have a portable generator (which they share with their next-door sister facility Summerset Lincoln Assisted Living and Memory Care), the generator was not functioning properly. Upon the power outage, the generator was not putting out voltage. The facility rented a portable generator to use. The generator service company determined there was a fuse that was burned out on the generator. The issue was immediately fixed and the company the yearly maintenance service. The facility immediately began to follow their Emergency and Disaster Plan by doing the following: renting a generator which supplied power to the common areas, contacting DME company to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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 59-AS-20240212120457

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING	FACILITY NUMBER: 312700555
	VISIT DATE: 03/11/2024

NARRATIVE

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provide oxygen tanks for residents, resident frequent checks by staff, and utilizing the emergency evacuation chair if residents needed to access a different floor. LPA determined that the facility did follow their emergency plan in place when there was a power outage.

Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Exit interview. A copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC9099 (FAS) - (06/04)

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