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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700555
Report Date: 07/29/2024
Date Signed: 07/29/2024 02:35:54 PM

Substantiated


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
07/19/2024 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240719114058
FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVINGFACILITY NUMBER:
312700555
ADMINISTRATOR:ROUZBEH MORADHASELFACILITY TYPE:
740
ADDRESS:550 2ND STTELEPHONE:
(916) 644-3151
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:162CENSUS: 100DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rouzbeh MoradhaselTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff mismanaged resident’s medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Monday July 29, 2024 to complete and deliver findings to a complaint received on 7/19/2024. LPA met with Administrator Rouzbeh and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed R1’s medication list, incident report, and hourly wellness checks. The result of the investigation is as follows:

LPA learned that the facility has two med techs to pass out AM shift medications. One med tech is assigned to the first floor while the other is assigned to the second floor. The third floor is divided between the two med techs. S1 provided S2 with a list of their assigned residents on the third floor. On July 19, 2024, S1 gave R1 their morning medications. Approximately 90 minutes later, S2 gave R1 a second dose of the same seven morning medications. Once the facility realized the medication error, the following people were contacted: poison control, R1’s primary physician, R1’s power of attorney, and management. Per the guidance of poison control, R1 was to be monitored hourly and did not need medical intervention.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20240719114058
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: 07/29/2024
NARRATIVE
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Based on the information detailed above, LPA finds the allegation to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240719114058
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care
The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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The facility terminated S2. Facility agrees to send LPA date/time for next staff training regarding medication errors by end of day 7/30/2024.
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based on interview stated that R1 received duplicate medications. This poses a direct threat to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3