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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700641
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:41:21 PM


Document Has Been Signed on 04/12/2023 02:41 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:HARUMI HURRIANKOFACILITY TYPE:
740
ADDRESS:110 STERLING COURTTELEPHONE:
(617) 796-8350
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:64CENSUS: 39DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Community Relations Director: Jane ScaparroTIME COMPLETED:
03:15 PM
NARRATIVE
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On 4/12/2023 at 9 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required- 1 Year inspection utilizing the inspection tool. LPA met with Community Relations Director (CRD), Jane Scapparo, and explained the purpose of the visit.

At 9:20 AM, LPA toured the interior and exterior of the facility together with CRD to ensure the health and safety of residents in care. Areas toured include but are not limited to: residents' bedrooms, bathrooms, common areas, maintenance room, kitchen, courtyard, and medication room. LPA observed required furniture, and lighting throughout the residents' bedrooms. Bathrooms are clean, sanitary, and in good repair. Toxic and cleaning supplies are locked in the maintenance room and is inaccessible to residents in care. LPA observed fire extinguishers, fire detectors, and carbon monoxide present at the facility. LPA observed food supplies of non-perishable for a minimum of one week and perishable foods for a minimum of two days. LPA observed medications were locked in medication carts and inaccessible to residents in care. Licensing posters are posted as required.

At 10:20 AM, LPA reviewed a total of five residents' files and five staff files. Five out of five residents' files contain signed Admission Agreements, Identification Sheet, Releases, Preplacement Appraisals, and Resident's Rights. Physician's Report for two out of Dementia residents did not have an updated annual medical assessment. Two (2) residents' Physician's Report were completed in 2021. Staff have training in Dementia, First Aid and CPR, and other various care provision. Med Tech have received required training in medications. At 1:20 PM, medications were reviewed for five residents. Medications are centrally stored, locked, and appear to be given per doctor's order.

LPA requested for ED to submit documents for review and records keeping.
  • Updated LIC500
  • Change of Administrator Request

There were deficiencies found in today's inspection. Deficiencies are cited from California Code of Regulations, Title 22, and citations are listed on LIC809-D. If the deficiencies are not corrected by the noted due date civil penalties may be assessed.

Exit interview conducted and appeal rights were provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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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Document Has Been Signed on 04/12/2023 02:41 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: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87705(c)(5)
87705(c)(5) Care of Persons with Dementia (c) Licensees who accep and retain residents with dementia shall be responsible for ensuring the following: Assesssment ... (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87455, medical and reappraisal done at least annually.
Deficient Practice Statement
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This requirement is not met as evidenced by: Based on interview and records review 2 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: 05/17/2023
Plan of Correction
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Facility shall submit updated physician's report by POC due date to CCL via email by 5/17/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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