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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700641
Report Date: 05/31/2023
Date Signed: 05/31/2023 01:46:18 PM


Document Has Been Signed on 05/31/2023 01:46 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: 44DATE:
05/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator: May TateTIME COMPLETED:
12:50 PM
NARRATIVE
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On 05/31/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to follow up on a Case Management- Incident visit conducted on 05/04/2023. LPA met with Executive Director (ED), May Tate, and explained the purpose of the visit.

During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, medication administration records (MAR), receipt of medications, and medication list.

The Department requested for R1’s physician’s report from the facility for review. The Department obtained an outdated physician’s report that was completed on 12/16/2021. According to physician’s report, R1 is diagnosed with Dementia and is unable to administer own prescription medications.

On 04/27/2023, LPA Keosavang received an email from ED stating the facility was conducting an internal investigation on R1’s medication error. LPA and ED scheduled a telephone call to go over findings of the internal investigation on 04/28/2023. On 04/28/2023, ED stated R1’s MAR indicates that the facility are giving medications to R1, however, if the facility is giving R1 medication they should have refilled those medications by the dates they were supposed to be refilled, but per facility’s nurse, R1’s RP dropped off medications at the facility, but the facility do not have records of when the medications were dropped off and how many medications were dropped off.

The Department received R1’s May 2022 through March 2023 MAR for review. According to R1’s MAR from May 2022 to July 2022, R1’s medications were given to R1. MAR for August of 2023 indicated, staff did not provide R1 Latanoprost on 08/07/2023 and 08/16/2023. On 09/25/2023, MAR indicates staff did not provide R1 Latanoprost. On 10/25/2023, MAR indicates staff did not provide R1 with Dorzolamide, Brimonidine, and Latanoprost. MAR for February of 2023 indicates all 4 medications were provided to R1. MAR for March of 2023 indicates staff did not provide R1 Dorzolamide, Brimonidine, and Rhopressa. MAR does not indicate a reason why medications were not provided to R1.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ROSEVILLE
FACILITY NUMBER: 312700641
VISIT DATE: 05/31/2023
NARRATIVE
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According to R1’s responsible party (RP), there are four (4) medications that are not given to R1 per doctor’s orders. Medication for Dorzolamide last filled date was on 08/26/2022 with a 3-month supply duration. Refill fate for Dorzolamide was on 11/26/2022. Medication instruction is to instill1 drop in both eyes 2 times a day for Glaucoma. Medication for Brimonidine last filled date was on 05/24/2022 with a 3-month supply duration. Refill for Brimonidine was on 08/24/2022. Medication instruction is to instill 1 drop in both eyes 3 times a day for Glaucoma. Medication for Latanoprost last filled date was on 12/26/2022 with a 75-day supply duration. Refill for Brimonidine was on 03/11/2023. Medication instruction is to instill 1 drop in both eyes daily at bedtime for Glaucoma. Medication for Rhopressa last filled date was on 12/26/2022 with 25-day supply duration. Refill for Rhopressa was on 01/20/2023. Medication instruction is to instill 1 drop in both eyes once a day for Glaucoma.

On 05/02/2023, an office meeting was conducted with R1’s RP to discuss medications concern. LPA Keosavang went over R1’s MAR and medication list with R1’s RP. R1’s RP provided LPA with boxes of the 4 medications listed above. RP stated RP was at the facility and had notified ED of concerns regarding medication not being given to R1. RP stated RP went over medication with the facility and observed medications to be full and unopened. RP took medications from the facility. RP stated if the facility is providing medications to R1 why are there boxes of unused medications. LPA confirmed the dates on the box of each medications matches the filled dates. LPA observed all 4 medications to be full and appears to not be given to R1.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the 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: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/31/2023 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ROSEVILLE
FACILITY NUMBER: 312700641

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2023
Section Cited
CCR
87465(c)(2)

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Incidental Medical and Dental Care (c ) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication ... requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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Administrator agrees to audit centrally stored medication. The facility will hold training with staff concerning medication management. The facility will send the staff sign in sheet and training syllabus. These documents will be due by the POC date of 06/01/2023.
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This requirement is not met as evidenced by: Based on observation, the facility did not ensure medication was given according to physician directions. During the review of medications, the LPA found
that for R1’s medications were found to be full and not given to R1.
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Type B
06/30/2023
Section Cited
HSC87705(c)(5)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of
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Facility agrees to schedule R1 by 6/09/2023 to get updated Medical Assessment and submit in updated Medical Assessments by 6/30/2023
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which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on records review, the facility did not comply with he section cited. R1 did not have updated medication assessment which poses a potential health, safety, or personal rights risk to person 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: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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