312700641-5-7-2025-59-AS-KHOS-DGPTET-20250515144029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700641
Report Date: 05/07/2025
Date Signed: 05/07/2025 12:47:38 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
02/04/2025 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20250204100350

FACILITY NAME:	SUMMERFIELD OF ROSEVILLE		FACILITY NUMBER:	312700641
ADMINISTRATOR:	MAY TATE		FACILITY TYPE:	740
ADDRESS:	110 STERLING COURT		TELEPHONE:	(916) 772-6500
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	64	CENSUS: 39	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jane Scaparro - Marketing Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained multiple unwitnessed falls due to staff neglect

INVESTIGATION FINDINGS:

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13

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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 6

Control Number 59-AS-20250204100350

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: SUMMERFIELD OF ROSEVILLE	FACILITY NUMBER: 312700641
	VISIT DATE: 05/07/2025

NARRATIVE

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***Report continued from 9099....

Allegation- Resident sustained multiple unwitnessed falls due to staff neglect
Based on documentation, between 03/12/2024 and 01/14/2025, R1 sustained nine unwitnessed falls in R1’s bedroom and one witnessed fall in the common area. Based on interviews, neither R1’s responsible party, or facility staff recommended a change in R1’s care plan or provided R1 with some type of ambulatory aid to possibly prevent R1 from falling. R1’s responsible party provided R1 a portable bed rail; however, R1 would remove the rail from the bed. Additionally, interviews revealed that neither R1’s responsible party nor facility staff recommended the use of an ambulatory aid because R1 would have “refused” to use it. Summerfield of Roseville has four neighborhoods on the premises: Garden, Tuscan, Apple, and Seaside. Seaside is a neighborhood for residents who need a higher level of care. Facility staff explained the residents living in Seaside can be considered fall-risks, may be wheelchair bound or receiving hospice services and require two-staff assistance. It was not recommended by facility staff that R1 move into this neighborhood for the higher level of care and supervision until 01/15/2025. Based on the findings, staff were neglectful in preventing R1 from sustaining falls while in care, therefore, the preponderance of evidence standard has been met, this allegation of Neglect/Lack of Care and Supervision is SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview conducted. Appeal rights provided. Report left with facility staff.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 59-AS-20250204100350

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: SUMMERFIELD OF ROSEVILLE	FACILITY NUMBER: 312700641
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/08/2025 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	The administrator agrees to write a plan of correction detailing how facility will address reassessments for resident’s who are documented fall risks. Additionally, the facility agrees to submit a plan on how staff will be trained and notified of resident’s who are fall risks and fall prevention protocols for each resident by 5/8/25.
	8 9 10 11 12 13 14	This requirement was not met based on facility failed to reassess R1 after resident sustained multiple falls. R1 sustained 9 falls between 03/12/24 and 01/14/25. This posed an immediate Health and Safety risk to residents 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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
02/04/2025 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20250204100350

FACILITY NAME:	SUMMERFIELD OF ROSEVILLE		FACILITY NUMBER:	312700641
ADMINISTRATOR:	MAY TATE		FACILITY TYPE:	740
ADDRESS:	110 STERLING COURT		TELEPHONE:	(916) 772-6500
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	64	CENSUS: 39	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jane Scaparro - Marketing Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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9

Resident sustained a fracture due to staff neglect

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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 6

Control Number 59-AS-20250204100350

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: SUMMERFIELD OF ROSEVILLE	FACILITY NUMBER: 312700641
	VISIT DATE: 05/07/2025

NARRATIVE

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Resident sustained a fracture due to staff neglect
Based on records reviewed, on 01/04/2025, around 1100 hours, R1 sustained an unwitnessed fall in R1’s bedroom. S1 located R1 on the floor next to R1’s bed. R1 complained of having back pain. S2 called emergency services and R1 was transported to the hospital by ambulance. Per medical
records, R1 arrived at the hospital on 01/04/2025, at 1115 hours. X-Ray images revealed that R1 had sustained an acute fracture of the transverse process of vertebra L1. Based on staff interviews and employee timesheets, R1 was last checked on by S1 on 01/04/2025, around 1000 hours, before S1 clocked out for S1’s lunch break at 1001 hours. Upon S1 returning from S1’s lunch at 1033 hours, S1 conducted another check on S1’s assigned residents, to prepare them for their lunch at 1130 hours. Considering the approximate one hour and fifteen-minute timeframe between R1 being checked on and R1 arriving at the hospital, I determined staff’s supervision of R1 was appropriate, and staff were not neglectful in their care; therefore, this allegation of Neglect/Lack of Care and Supervision is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Report left with facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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
02/04/2025 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20250204100350

FACILITY NAME:	SUMMERFIELD OF ROSEVILLE		FACILITY NUMBER:	312700641
ADMINISTRATOR:	MAY TATE		FACILITY TYPE:	740
ADDRESS:	110 STERLING COURT		TELEPHONE:	(916) 772-6500
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	64	CENSUS: 39	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jane Scaparro - Marketing Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Licensee did not ensure resident's responsible person received a detailed explanation of the services to be provided at the new level of care
Licensee did not ensure resident's responsible person received an itemization of charges

INVESTIGATION FINDINGS:

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On May 7, 2025 Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Jane Scaparro - Marketing Director. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:
Based on records reviewed, department observed a detailed explanation of the services provided at the new level of care and observed RP’s signature and facility signature on the itemization of charges at this new level of care, confirming receipt of the documents. Therefore, the allegations above are UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. Report left with facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 6