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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 02:42:31 PM

Document Has Been Signed on 04/12/2023 02:42 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Community Relations Director: Jane scaparroTIME COMPLETED:
03:30 PM
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On 4/12/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident inspection. LPA met with Community Relations Director (CRD), Jane Scapparo, and explained the purpose of the visit.

The purpose of the visit is to follow-up on two unusual incident/injury reports that was submitted to Community Care Licensing (CCL) on 03/31/2023. Incident report indicated on 03/28/2023, a quarterly audit was conducted by Omnicare Pharmacy, per community request. During the audit, it was found that residents (R1 and R2), had not been receiving their medications for administration. The facility requested for R1's and R2's medication refills. R1 and R2's physician's were notified. R1 and R2 were observed by staff for 48 hours for any changes related to missed medications. On 4/5/2023, all of the medication technicians will receive mandatory training on the process of reordering medications and procedures to follow when a medication does not have any refills. LPA interviewed CRD regarding the two incident reports. CRD stated facility is currently switching over to use online eMARS which will be easier to staff to track medications. LPA requested for audit documents for review.

At this time no deficiencies are being cited.

Exit interview conducted and report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
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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