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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700641
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:21:31 PM


Document Has Been Signed on 05/04/2023 02:21 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:SUMMERFIELD OF ROSEVILLEFACILITY NUMBER:
312700641
ADMINISTRATOR:MAY TATEFACILITY TYPE:
740
ADDRESS:110 STERLING COURTTELEPHONE:
(617) 796-8350
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:64CENSUS: 41DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Executive Director: May Tate TIME COMPLETED:
02:30 PM
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On 05/04/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident to obtain information regarding an incident that occurred at the facility on 04/13/2023. LPA met with Executive Director (ED), May Tate, and explained the purpose of the visit.

The Case Management visit is in response to a telephone call and incident report that was submitted to CCLD. The report indicates resident (R1) responsible party (RP) was present at the facility on 04/13/2023. RP notified the facility that R1 is going blind in left eye due to staff not giving eye drops to R1. RP indicated R1’s eye drops have not been refilled in a while. The facility conducted an internal investigation. The facility reviewed R1’s medication administration records (MAR) to see if staff had been signing off, checked medication cart to see how many eye drops are currently in use, and how many backups are left. Facility had contacted R1’s pharmacy and confirmed refill dates. Facility interviewed Med Techs and confirmed they have been giving eye drops to R1. The facility reported the incident to CCL and Local Long Term Care Ombudsman. According to facility, RP refilled all 4 eye drops and dropped them off to the facility on 04/18/2023.

LPA Keosavang requested for R1’s physician’s report, doctor's orders for medications, medication list, and MAR for review. LPA conducted interviews with facility staff. The ED was advised that at this time possible follow-up telephone calls or visits are necessary for further investigation.

At this time, deficiencies are not being cited.

An exit interview conducted and report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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