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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700641
Report Date: 02/03/2023
Date Signed: 03/07/2023 02:09:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
11/04/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221104151132
FACILITY NAME:SUMMERFIELD OF ROSEVILLEFACILITY NUMBER:
312700641
ADMINISTRATOR:TAYLOR, DEBORAHFACILITY TYPE:
740
ADDRESS:110 STERLING COURTTELEPHONE:
(617) 796-8350
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:64CENSUS: 39DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Resident Service Director- Jasmine JuchniewiczTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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- Resident forced to take medication against her will.
- Resident Restrained.
INVESTIGATION FINDINGS:
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This report was amended on 03/07/2023.

Administrator listed above is not the facility's administrator. Current administrator is Harumi Hurrianko.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 02/3/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 11/04/2022. LPA met with Resident Service Director, Jasmine Juchniewicz, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, identification, and emergency information, needs and services plan, SOC 341, medication list, admission agreement, unusual incident/injury report, facility’s abuse policy training for staff, and written statements from agency staff.

Continued on page LIC-9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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 25-AS-20221104151132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SUMMERFIELD OF ROSEVILLE
FACILITY NUMBER: 312700641
VISIT DATE: 02/03/2023
NARRATIVE
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According to complainant, caregivers from Bright Star agency forced R1 to take medication against R1’s will. The Department reviewed R1’s physician’s report which indicated R1 ‘s primary diagnosis is Alzheimer’s disease. R1 is able to administer own medication and able to administer own PRN medication when handed directly to R1. An unusual incident/injury report was submitted to CCL for review. Incident report indicated a registry Med Tech notified the facility that two other registry staff were assisting Med Tech with providing medication to R1 in the evening of 10/25/2022. According to Med Tech, the two staff were assisting R1 and the Med Tech was inappropriate.

The Department requested and reviewed written statement from two (2) registry staff provided by Bright Star Agency. Written statement from S1 indicated R1 refused to take medication twice. S1 assisted by holding R1’s face and S2 held on R1’s shoulders. Written statement from S2 indicated, S2 gently held on to R1's shoulders while S1 got R1 to open her mouth. S2 denied restraining resident.

Interview statement gathered from S1 indicated, S1 had put her hand under R1's chin and S2 hands were on R1's forehands. S1 stated R1 did not fully take the medication only a portion of it. S1 indicated if a resident refuses to take medication sometimes staff would just put "medication with apple sauce." Interview statement gathered from S2 indicated, S2 suggested for Med Tech to indicate on R1’s Medication Administrator Records (MAR) that R1 refused, but Med Tech insisted that R1 needed to take medication for agitation to prevent R1 from lashing out at staff and other residents. S2 confirmed that S2 held on R1’s arms and shoulders while S1 was holding R1’s mouth. S2 indicated staff were partially success in providing medication to R1.

The Department requested for S3's Med Tech credentials and medication training for review. The facility did not have records of S3's credentials or any medication training provided to S3.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegations 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.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20221104151132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUMMERFIELD OF ROSEVILLE
FACILITY NUMBER: 312700641
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily
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Resident Service Director, Jasmine Juchniewicz, agrees to conduct staff training on resident's personal rights. ED is to submit proof of training and indicate what topics were discussed and staff to sign off on training, by POC due date, 02/10/2023.
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living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on interviews and documentation reviewed, R1 refused medication twice and three (3) facility staff restrained R1 physicially when assisting with medication. This poses an immediate health and safety risk to resident in care.
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Type A
02/10/2023
Section Cited
CCR
87465(a)(5)(D)
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87465(a)(5)(D) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed... include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
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Resident Service Director, Jasmine Juchniewicz, agrees to conduct staff training on medication refusal and submit proof of training on POC due date, 2/10/2023.
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 This requirement was not met as evidenced by: Based on interviews and documentation reviewed, R1 refused medication twice and facility staff had physically restrained R1 and insisted for R1 to take medication. This poses an immediate health and safety ricks to resident 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: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 25-AS-20221104151132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SUMMERFIELD OF ROSEVILLE
FACILITY NUMBER: 312700641
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
HSC
1569.69(a)(1)
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§1569.69 Employees assisting residents with self-administration of medication; training requirements. (a) Each residential care facility ... the employee shall complete 16 hours of initial training. This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications,
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Resident Service Director, Jasmine Juchniewicz, agrees to review
Health and Safety Code 1569.69 and submit letter of understanding to CCL by POC due date, 02/10/2023.
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 and eight hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. Based on interviews, facility does not have records of S3's medication training or credentials. This poses an immediate health and safety ricks to resident 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: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
11/04/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20221104151132

FACILITY NAME:SUMMERFIELD OF ROSEVILLEFACILITY NUMBER:
312700641
ADMINISTRATOR:TAYLOR, DEBORAHFACILITY TYPE:
740
ADDRESS:110 STERLING COURTTELEPHONE:
(617) 796-8350
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:64CENSUS: 39DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Harumi Hurrianko- Executive Director TIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Resident forced to eat against her will.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 02/3/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 11/04/2022. LPA met with Resident Service Director, Jasmine Juchniewicz, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, identification, and emergency information, needs and services plan, and admission agreement.

Continued on page LIC-9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20221104151132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: SUMMERFIELD OF ROSEVILLE
FACILITY NUMBER: 312700641
VISIT DATE: 02/03/2023
NARRATIVE
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The Department received and reviewed R1's physician's report. According to R1's physician's report, R1's primary diagnosis is Alzheimer's Disease. R1 is able to feed self. According to R1's assessment completed on 11/09/2022, R1 requires reminders for meals and eats independently with no meal adjustments.

According to complainant, R1 was forced to eat against will. The Department interviewed and gathered statement from a total of five (5) facility staff. All five (5) facility staff denied witnessing or being involved in forcing R1 to eat against will. Interview statement received from R1 confirmed staff did not force R1 to eat against will.

CCL finds the allegation to be UNSUBSTANTIATED, meaning 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, and the findings are unsubstantiated.

Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6