347005361-1-25-2021-27-AS-MSEY-BXQU76-20210129141926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 01/25/2021
Date Signed: 01/25/2021 03:12:33 PM

Unsubstantiated

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
01/01/2021 and conducted by Evaluator Melana Llopis

COMPLAINT CONTROL NUMBER: 27-AS-20210101154714

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: 112	DATE:	01/25/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Executive Director, Tracy McLinn		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff members are not wearing facemasks while in the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis contacted the facility via telephone on 01/25/2020 to deliver complaint findings over the phone due to COVID-19 and precautionary measures. LPA spoke with the Executive Director, Tracy McLinn and explained the purpose of the telephone call.

Throughout the course of the investigation Community Care Licensing (CCL) conducted interviews, reviewed video footage and reviewed documentation regarding the allegation: Staff members are not wearing facemasks while in the facility.

Results are as follows:

***Report continued on LIC 9099-C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melana Llopis
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210101154714

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: 01/25/2021

NARRATIVE

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On 01/08/2021, LPA Llopis opened up a complaint received on 01/01/2021 stating staff were not wearing their Personal Protective Equipment (PPE), specifically face masks. LPA requested pertinent documents, video footage, and photos of the facility PPE storage room and supply. On 01/12/2021, 01/19/2021, and 01/20/2021 LPA reviewed documents, video footage, and photos. LPA found the facility has mandated all staff employees to wear their PPE facemasks at all times while working in the facility. LPA observed the facility has a sufficient amount of PPE which includes N95 facemasks and surgical masks. LPA observed from the randomly selected video footage staff were wearing their facemasks while working in the facility.

Then on 01/19/2021, LPA interviewed a random sample of six (6) of six (6) residents in care and five (5) of five (5) staff working at the facility. Interviews with residents indicate the facility staff are wearing their masks while providing direct care to residents. Residents stated "staff are always wearing their masks," "I do not remember them not wearing their masks," and "every one of the staff wear their masks." Interviews with staff reported that "staff are always wearing their masks when working with residents."

On 11/30/2020 and 01/21/2021 LPA Llopis conducted Welfare Calls with Executive Director, Tracy McLinn. No concerns were present regarding infection control. The facility has been in communication with CCL throughout the pandemic and has been cooperative with CCL's direction and Public Health's recommendations.

Based records reviewed and interviews conducted, LPA find the allegation, Staff members are not wearing facemasks while in the facility.to be UNSUBSTANTIATED, meaning although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Due to the findings, no deficiencies are being cited today.

Exit interview conducted via telephone with Executive Director, Tracy McLinn. Copy of report provided via email. The facility will print, sign and send back a signed copy to CCL by 01/26/2021.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melana Llopis
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

LIC9099 (FAS) - (06/04)

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