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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700555
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:14:17 PM


Document Has Been Signed on 01/04/2024 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
312700555
ADMINISTRATOR:MORRIS, SHALONFACILITY TYPE:
740
ADDRESS:550 2ND STTELEPHONE:
(916) 644-3151
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:162CENSUS: 99DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jeff DoolittleTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday January 4, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (10) and staff (8) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA along with Jeff and future Administrator Rouzeh Moradhasel toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, resident bathrooms, common areas, kitchen, laundry rooms, medication rooms, and balconies. LPA observed the facility's emergency food, water storage and PPE. In the areas toured, there were no health or safety violations observed.

LPA requested an updated LIC500 and LIC610E. Additionally, LPA requested a copy of the current liability insurance.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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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