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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700555
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:11:20 AM

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
05/15/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230515154653
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: 94DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jeff DoolittleTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident was charged for services not rendered
INVESTIGATION FINDINGS:
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LPA Parks arrived on August 31, 2023, to conclude a complaint investigation regarding the above allegation. LPA met with Administrator Jeff and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed R1’s file including hospital discharge paperwork, MARs, billing records and resident notes.

Based on MARs and hospital discharge paperwork, LPA determined that R1 was out of the facility for the following date: 2/11/23 – 2/13/23, 4/13/23-4/21/23, 3/21/23 – 3/28/2023. Per the signed admission agreement, the facility stops charging for care fees once the resident is out for over 7 days. Based on the admission agreement, R1 is due a care credit for three days (one day for the absence in March and two days for the absence in April). Based on R1’s transaction history, the facility only applied a credit for room service trays, but not for care fees.

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: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 5
Control Number 59-AS-20230515154653
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: 08/31/2023
NARRATIVE
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Based on the information detailed above, LPA finds that the allegation is substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies 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: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20230515154653
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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:
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Administrator agrees to provide LPA with a copy of check for credited care days.
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based on document review and interview, the licensee did not company with the section cited above by not crediting R1’s account for 3 care days per the admission agreement, which poses a potential health, safety or personal rights risk to the persons 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: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/15/2023 and conducted by Evaluator Melissa Parks
COMPLAINT CONTROL NUMBER: 59-AS-20230515154653

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: 94DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jeff DoolittleTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not fix light in resident's room timely.
Staff serve cold food to residents.
Staff do not answer call bells timely.
Staff did not refund authorized representative for late charge incurred.
Staff did not itemize the invoice for authorized representative.
INVESTIGATION FINDINGS:
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LPA Parks arrived on August 31, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Jeff and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, facility staff, and current residents. LPA reviewed R1’s file including R1’s physicians report, hospital discharge paperwork, MARs, care plan, billing records and resident notes.

LPA interviewed staff who stated they did not remember R1’s light being out in their apartment. Per staff, R1 would only turn the lights on at night. R1 preferred to use the light from the window during the day. LPA interviewed the Maintenance Director who did not have any records of replacing a light in R1’s apartment. Per the Maintenance Director, all ceiling lights are LED and last for years.

LPA reviewed billing for R1. Per the account ledger, there is no late fee charged to the account. The account ledger shows that there are charges for rent, care fees, and room tray fees.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20230515154653
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: 08/31/2023
NARRATIVE
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LPA interviewed residents. All residents interviewed stated that the food is served warm/hot in the dining room. Per staff interviewed, R1 sat at a table in the dining room which is directly below an AC vent. Staff interviewed stated that resident’s have not complained to them about food being served cold in the dining room.

LPA reviewed call logs records for residents. Staff interviewed stated that they strive to answer call buttons within 10-15 minutes. Staff acknowledged that at times, during mealtimes when many residents press their pendants at the same time, it can take longer to answer the call buttons. Residents interviewed stated that staff answer the pendants timely.

Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred,

Exit interview. 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: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5