347005361-1-11-2021-27-AS-MSEY-BX8LZC-20210113081143

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 01/11/2021
Date Signed: 01/11/2021 02:31:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2020 and conducted by Evaluator Melana Llopis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200604142743

FACILITY NAME:	SUMMERSET ASSISTED LIVING		FACILITY NUMBER:	347005361
ADMINISTRATOR:	GOLZE, RYAN		FACILITY TYPE:	740
ADDRESS:	2341 VEHICLE DR		TELEPHONE:	(916) 330-1300
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95670
CAPACITY:	135	CENSUS: 113	DATE:	01/11/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Executive Director, Tracy McLinn		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not provide resident with clean linen.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Llopis contacted the facility on to deliver findings for a complaint Community Care Licensing (CCL) received on 06/04/2020 via telephone due to COVID-19 and pre-cautionary measures, LPA spoke with Executive Director (ED) Tracy McLinn and explained the purpose of the call.

Throughout the course of the investigation CCL reviewed documentation and conducted interviews regarding the allegation: Staff did not provide resident with clean linen.
Allegation:Staff did not provide resident with clean linen.

Results are as follows:

***Continuation on 9099-C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2021

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 5

Control Number 27-AS-20200604142743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
	VISIT DATE: 01/11/2021

NARRATIVE

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Allegation: Staff did not provide resident with clean linen.

On 04/18/2020, resident (R1)'s bed was found made with soiled linens. Statements from eye witness and staff confirmed the facility did not change R1's sheets or remove soiled linens right after they recognized the sheets were soiled. Interviews with five (5) of five (5) staff reported the facility protocol for cleaning soiled linens requires staff to remove linens right away and if possible wash linens immediately.

Due to this information, the preponderance of evidence standards has been met, and therefore the allegation in this complaint is found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit.

Exit interview conducted, appeal rights provided, and a copy of report will be emailed to facility. Facility will print, sign, and send CCL a signed copy of the report.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2020 and conducted by Evaluator Melana Llopis

COMPLAINT CONTROL NUMBER: 27-AS-20200604142743

FACILITY NAME:	SUMMERSET ASSISTED LIVING		FACILITY NUMBER:	347005361
ADMINISTRATOR:	GOLZE, RYAN		FACILITY TYPE:	740
ADDRESS:	2341 VEHICLE DR		TELEPHONE:	(916) 330-1300
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95670
CAPACITY:	135	CENSUS:	DATE:	01/11/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Executive Director, Tracy McLinn		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.
Staff did not provide adequate supervision to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Llopis contacted the facility on to deliver findings for a complaint Community Care Licensing (CCL) received on 06/04/2020 via telephone due to COVID-19 and pre-cautionary measures, LPA spoke with Executive Director (ED) Tracy McLinn and explained the purpose of the call.

Throughout the course of the investigation CCL reviewed documentation and conducted interviews regarding the allegations:Staff handled resident in a rough manner and staff did not provide adequate supervision to resident in care.

Results are as follows:

***Continuation on 9099-C***

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20200604142743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
	VISIT DATE: 01/11/2021

NARRATIVE

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Allegation: Staff handled resident in a rough manner.

After conducting interviews with staff, residents and local ombudsman, and reviewing documentation, it was learned that no other witness or evidence could verify resident (R2) being handled roughly by staff. Documents reviewed for R2 show no incidents resulting in bruising were reported. R2's responsible party stated they "face-time R2 twice a week, R2 always appears well groomed and cared for, and they did not have concerns with R2's care." Due to R2's dementia diagnosis, LPA was unable to interview R2 as a viable witness. However, three (3) of three (3) residents interviewed reported the facility staff treat them "well" and do a "good job" with their care. Interviews with staff stated they have not witnessed staff treat residents roughly.

Allegation: Staff did not provide adequate supervision to resident in care.

Interviews with residents and staff, and documents reviewed indicate residents in care are scheduled to receive two (2) hour checks throughout the 24 hour day period. Documents reviewed for the months of April and May 2020 show R1 and R2 received their two (2) hour checks. Interviews with three (3) residents stated the facility checks on them regularly, the staff are "outstanding" and "wonderful" and they are "satisfied with their care." ADL charts reviewed for R1 and R2 indicate R1 and R2 received daily assistance for required needs.

Due to the above information, the Department finds the allegations to be UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Administrator to review, sign, and return a signed copy of this report within 10 days.

Exit interview and report provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20200604142743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/25/2021 Section Cited CCR 87307(3)(C)	1 2 3 4 5 6 7	Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.	1 2 3 4 5 6 7	Licensee agrees to retrain all staff on cleaning protocols and policies. Licensee will send a signed documentation that training was completed for all staff by POC date.
	8 9 10 11 12 13 14	Based on interviews conducted and documents reviewed, this requirement was not as evidenced on 04/18/2020, resident (R1)'s bed was found made with soiled linens. This caused a potential health and personal rights risk to resident 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: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2021

LIC9099 (FAS) - (06/04)

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