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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700555
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:50:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2021 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211229104720
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: 91DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Denise Carrillo, filling in as Business Office DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are not wearing masks
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 07/22/2022 to conduct a complaint investigation for the above allegation. LPA met with Denise Carrillo, who is filling in as Business Office Director as the Executive Director and Business Office Director are both out, and explained the purpose of the visit. Prior to the visit , LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask.

During today’s visit, LPA spoke with staff (S1, S2, and S3), toured the facility and reviewed documents. LPA observed five (5) staff not wearing masks, and only (1) staff wearing their mask. As a result of this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted. A copy of this report and appeal rights were printed and provided to Denise Carrillo.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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 25-AS-20211229104720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 312700555
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2022
Section Cited
CCR
80072(a)(2)
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Personal Rights. (a) Each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Executive Director or Staff In-Charge to review recent PINs and submit a statement of understanding that masks shall be worn by staff in the care home by the POC due date of 08/05/22.
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Based on interviews and observation, LPA observed 5 staff not wearing masks in the facility on 7/22/2022 which poses an immediate health and safety risk to 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2021 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211229104720

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: DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:DeniseTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing consistent care
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
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13
Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 07/22/2022 to conduct a complaint investigation for the above allegation.

During today’s visit, LPA spoke with staff (S1, S2, and S3), toured the facility and reviewed documents. R1 has since moved out of state, and while reviewing their "resident notes", the notes were incomplete as they only show four staff note entries across the residents entire time living at Summerset. One of the notes logged from 12/26/2021 states staff visited R1 while she was on isolation for COVID, stating she had no concerns. Because the notes on file are inconsistent, there is not a preponderance of evidence to prove that she was not checked on enough while on isolation. 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. Copy of report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3