312700641-4-20-2022-25-AS-KHOS-CDUH6A-20220426055450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700641
Report Date: 04/20/2022
Date Signed: 04/20/2022 12:17:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220419135522

FACILITY NAME:	SUMMERFIELD OF ROSEVILLE		FACILITY NUMBER:	312700641
ADMINISTRATOR:	TAYLOR, DEBORAH		FACILITY TYPE:	740
ADDRESS:	110 STERLING COURT		TELEPHONE:	(617) 796-8350
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	64	CENSUS: 39	DATE:	04/20/2022
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Jane Scaparro- Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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- Facility has mold.
- Kitchen equipment is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility and met with Executive Director (ED), Jane Scaparro, to open a complaint investigation into the allegations listed above. LPA wore Surgical mask and was screened by facility upon entry.LPA toured the interior of the facility together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, and kitchen. LPA observed mold on the kitchen ceiling. Kitchen equpiment such as ice machine, mixer, and oven is in disrepair.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220419135522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUMMERFIELD OF ROSEVILLE	FACILITY NUMBER: 312700641
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/21/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Executive Director agrees to schedule an appointment for a mold remediation company to come out to facility to inspect the kitchen by POC date, 04/21/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation the licensee did not ensure that facility kitchen is free from mold which poses an immediate health and safety risk to residents in care. LPA also observed kitchen equipment such as ice machine, mixer, and oven to be in disrepair.	8 9 10 11 12 13 14	Executive Director agrees to get the oven and the ice machine repaired by 04/27/2022.
	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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

LIC9099 (FAS) - (06/04)

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