312700555-6-27-2024-59-AS-MSEY-D6TMAW-20240703092701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700555
Report Date: 06/27/2024
Date Signed: 06/27/2024 11:03:34 AM

Unfounded

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
05/08/2024 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240508150927

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: 94	DATE:	06/27/2024
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Rouzbeh Moradhasel		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility staff did not dispense medications as prescribed
Facility staff did not assist resident with dressing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday June 27, 2024, to complete and deliver findings for a complaint received on 5/8/2024. LPA met with Administrator Rouzbeh and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed facility staff including the Administrator, Resident Services Director, Wellness Director, med techs, and caregivers. LPA reviewed R1’s file including PRN authorization, controlled drug records, communication with primary physician, resident assessment, physician reports, resident notes, physician orders, and PRN MAR.

LPA interviewed staff who revealed that R1 is able to communicate when they are in pain. R1 had PRN orders for Tramadol 50mg for moderate oto severe pain and acetaminophen 325 mg as needed for pain. No staff interviews revealed that R1 was ever refused pain medication. LPA did review a faxed message to R1’s primary physician, requesting a refill order for Tramadol. R1 has a primary diagnosis of CHF exacerbation and mild cognitive impairment. R1, at times, has refused to get out of bed. No staff

Unfounded

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: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

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-20240508150927

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: 06/27/2024

NARRATIVE

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interviews acknowledged that R1 was refused assistance with dressing or care .

Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was left at the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC9099 (FAS) - (06/04)

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