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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 06/23/2022
Date Signed: 08/12/2022 03:50:48 PM


Document Has Been Signed on 08/12/2022 03:50 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SUMMERSET ASSISTED LIVINGFACILITY NUMBER:
347005361
ADMINISTRATOR:BEASLEY, CARLIEFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:135CENSUS: 103DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alicia WeathersTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez and Navdeep Singh made an unannounced visit to conduct an annual inspection on 06/23/2022 at 11:30 AM. LPA met with Alicia Weathers and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for 115 non-ambulatory residents, 55 dementia residents, 20 bedridden residents, and 21 hospices residents. There are currently 103 residents and 10 hospice residents. The LPA Martinez and Navedeep Singh toured the facility with Alicia on 06/23/2022 at 2:00 PM.

The facility has one main entry COVID-19 screening area. The facility has covid-19 positing throughout the facility. The facility has hand sanitizer throughout the facility. The common area furniture is spaced 6 feet apart. The facility conducts disinfection cleaning daily. The facility was sanitary, and the facility temperature was 78 degrees. Water temperature was inspected in two residents rooms and at kitchenette on second floor. Water temperatures were as follows: 105, 108, and 115 degrees. LPA inspected fire extinguishers and last fire inspection was on 09/28/2021. The facility last fire drill was on 06/21/2022. The facility had an adequate food supply. LPA Martinez observed unlock cleaning supplies at second floor kitchenette. LPA Martinez observer a resident in the kitchenette during the time kitchen cleaning supplies were unlocked. LPA Martinez reviewed two resident files and two employee files. Two out of two resident files were up to date. One out of two staff files was not complete during file review. Staff 1 file was missing a document. The missing document information was verified, and the document was requested from primary care physician and received during the visit . A technical violation advisory was given. An exit interview was conducted, and copy of the 809 report, 809-D, appeals rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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 08/12/2022 03:50 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
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: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2022
Section Cited

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87705(f)(2)Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement was not met as evidence by: Based on observation, toxins were made accessible to Dementia residents on the second floor. This posed an immediate health and safety risk to residents 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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