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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700555
Report Date: 03/23/2022
Date Signed: 03/23/2022 12:50:12 PM


Document Has Been Signed on 03/23/2022 12:50 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SUMMERSET LINCOLN ASSISTED LIVINGFACILITY NUMBER:
312700555
ADMINISTRATOR:BOYLE, SABRINAFACILITY TYPE:
740
ADDRESS:550 2ND STTELEPHONE:
(916) 644-3151
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:162CENSUS: 82DATE:
03/23/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Sabrina Boyle- Executive Director TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 3/23/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director, Sabrina Boyle, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and LPA completed a facility risk assessment at the facility. LPA ensured the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA toured the interior and exterior of the facility together with Director of Systems Operations, Andy Dahlar, to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, two (2) bathrooms, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Executive Director completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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