347005361-2-21-2024-27-AS-KHOS-D33L3R-20240305072420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 02/12/2024
Date Signed: 02/21/2024 02:32:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240119151219

FACILITY NAME:	SUMMERSET ASSISTED LIVING		FACILITY NUMBER:	347005361
ADMINISTRATOR:	ELISA WEATHERS		FACILITY TYPE:	740
ADDRESS:	2341 VEHICLE DR		TELEPHONE:	(916) 330-1300
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95670
CAPACITY:	135	CENSUS: 86	DATE:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Danielle Barry		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff does not ensure resident receives assistance with wheelchair
Staff does not ensure resident is brought down for meal service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with Danielle Barry and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed a resident (R1) and five staff members (S1-S5). LPA Moleski reviewed R1’s file. R1’s assessment states that R1 is to receive two-person assistance with transfers. R1’s preplacement appraisal states that R1 needs assistance getting into R1’s wheelchair. R1 is unconserved and has no powers of attorney documented.

R1 was admitted to the facility as of December 11, 2023. In an interview on January 25, 2024, R1 said that R1 was not comfortable with transferring out of bed upon admission, that R1 suffered pain when trying to get up, and that R1 suffered from nausea when out of bed for too long. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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-20240119151219

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
	VISIT DATE: 02/12/2024

NARRATIVE

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R1 said staff are able to assist with transfers when requested, and said that staff are “great.” R1 said staff use a Hoyer lift to transfer R1. R1 said that R1 did not mind having meals delivered rather than eating in the dining room. During the interview, R1 raised concerns regarding staffing levels and regarding bathing services, which were addressed on complaint #27-AS-20231204145833. Corrective action regarding those allegations has been initiated.

The Community Care Licensing Division received an incident report dated 1/29/24 which stated that R1’s Hoyer lift broke on 1/25/24. LPA Moleski interviewed R1 again on 2/1/24 while R1 was in a wheelchair in the dining room. R1 said that staff were able to transfer him to the wheelchair without the Hoyer lift.

During interviews, S1-S5 said that R1 was assisted with transfers when R1 asked for transfers, but R1 did not often want to be transferred due to pain and weakness when attempting to do so. Staff said that R1 often preferred to stay in bed and have meals delivered.

The department has determined the following as it relates to the allegations that staff does not ensure resident receives assistance with wheelchair and that staff does not ensure resident is brought down for meal service:

Based on interviews and observation, the above allegation is UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

This report was amended on 2/21/24 to reflect that this report is a public document.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Barry.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

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