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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700641
Report Date: 04/24/2024
Date Signed: 04/24/2024 02:21:04 PM


Document Has Been Signed on 04/24/2024 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 52DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator May TateTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived on 4/24/24 to conduct the annual inspection. LPAs met with Administrator May Tate and explained the purpose of the visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (5) and staff (5) files. All the required postings were observed.

LPAs and Administrator May Tate toured the facility together to ensure the health and safety of residents in care. The areas toured included kitchen, hallways, memory care apartments, memory care dining room/kitchen, and memory care common areas. Water temperatures in the apartments toured were within the required range of temperature. LPAs observed the facility's emergency food and water storage. LPAs observed fire extinguisher is ready for emergency use. In the areas toured, there were no health or safety violations observed. LPAs reviewed fire drills.

LPAs requested the facility to send updated LIC500, LIC610E and current liability insurance to be sent to the Department by 5/15/24.

Deficiencies were observed per Title 22 regulations from today's visit as indicated on 809-D.

Exit interview conducted. Appeal rights and copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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Document Has Been Signed on 04/24/2024 02:21 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SUMMERFIELD OF ROSEVILLE
FACILITY NUMBER: 312700641

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviewed, LPA observed that health screening and TB is missing 1 out of 5 files, and 5 out of 5 were missing a job application, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Facility shall complete all required documents for all staff files per this regulation and will send proof to department by POC date 5/15/2024.
Type B
Section Cited
CCR
87705(c)(5)
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 which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review 3 out of 5 residents did not have updated physician's report in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Facility shall submit updated physician's report by POC due date to CCL via email by 5/15/2024.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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