<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700555
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:19:54 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
09/11/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230911134523
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: 95DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Jeff DoolittleTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident’s medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday September 28, 2023, to complete and deliver findings to a complaint received on 9/15/2023. LPA met with Administrator Jeff and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator and Wellness Director. LPA interviewed R1 and R2 regarding the allegations. LPA reviewed R1’s file at the facility including physicians report, progress notes, and MARs. The result of the investigation is as follows:

On 8/13/2023, R1 was running low on two medications (Atrovastatin and Amloidipine). Staff reordered the medication, however, not within the timeframe for resident to not miss any doses. Additionally, one medication needed the primary physician’s signature for the prescription to be renewed. Based on interviews, R1 was out of one medication as of 8/15 or 8/16 (unsure due to inconsistent documentation on MARs). Based on R1’s MARs, one medication was out for 3 days and the other for 5 days.
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: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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-20230911134523
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: 09/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

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: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20230911134523
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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
87465(a)(5)
Incidental Medical and Dental Care
The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: based on interview and MAR document review, resident was not
1
2
3
4
5
6
7
Administrator to submit plan of med tech training regarding medications.
8
9
10
11
12
13
14
 given medication as prescribed. This poses a direct risk to the health and safety of resident in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
09/11/2023 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230911134523

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: 95DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Jeff DoolittleTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to a lack of staff, the residents food is not brought timely
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday September 28, 2023, to complete and deliver findings to a complaint received on 9/15/2023. LPA met with Administrator Jeff and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the Administrator, Wellness Director, and staff. LPA interviewed R1 and R2 regarding the allegations. The result of the investigation is as follows:

LPA learned that R1 and R2 were temporarily eating meals in their apartment due to an illness. R1 and R2 only eat two meals at the facility, a late breakfast and dinner. Per interviews, R1 and R2 want their meals delivered at specific times. Staff stated that they due their best to deliver at the requested time. However, resident care needs, will at times, disrupt the tray delivery. Based on interviews, meals can sometimes take 30 minutes to be delievered. LPA reviewed the facility's admission agreement which only discusses meal tray delivery charges. Therefore, there is no guaranteed delivery time for meal times. Interviews from staff stated that staff are scheduled in order to meet resident care needs. Meal tray deliveries are an uncommon
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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-20230911134523
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: 09/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
occurrence as it is for temporary amount of time.

Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegation is 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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5