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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:16:52 PM

Substantiated


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
02/20/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240220140418
FACILITY NAME:SUMMERSET ASSISTED LIVINGFACILITY NUMBER:
347005361
ADMINISTRATOR:ELISA WEATHERSFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:135CENSUS: 86DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Danielle BarryTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff do not follow infection control protocols.
Staff are not addressing a scabies outbreak.
Staff did not report a scabies outbreak as required.
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 facility administrator Danielle Barry and explained the purpose of the visit.

LPA Moleski toured the second floor and met with a resident (R2). LPA Moleski reviewed hospital discharge paperwork for R2. R2 was diagnosed with scabies on 4/9/24, according to the discharge paperwork. R2 returned to this facility on 4/10/24.

LPA Moleski visited R2's room and observed two caregivers (S2 and S3) applying ointment to R2 in bed. S2 and S3 were wearing gloves, but were not wearing gowns or masks. LPA Moleski observed gloves discarded in an uncovered trash can inside R2's room. LPA Moleski observed S3 discard used gloves in an uncovered trash can in a common area.

[continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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-20240220140418
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: 04/15/2024
NARRATIVE
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In an interview, Barry said she had not been in contact with public health regarding infection control requirements since R2's return to the facility. Barry was not aware that R2 had been diagnosed with scabies while at the hospital. 22 CCR Sections 87470(b)(1)(A) and 87470(b)(2)(A) state that the licensee shall report to a local health department or similar authority for guidance on proper PPE usage and proper environmental cleaning practices when one or more residents are diagnosed with a contagious disease.

LPA Moleski interviewed a hospice nurse for a resident (R1). The nurse said R1 did not have scabies, but reported seeing several residents with wounds and itchy. R1 was treated with permethrin. In an interview, S1 said that the facility was instructed to use the permethrin as a precaution. S1 said that there were two other residents as of early March also taking permethrin (R3 and R4). S1 said that there was a scabies outbreak in 2023, and the same residents still had rashes. In an interview, S2 said that there was a scabies outbreak in 2023. S2 said there were a small number of residents with rashes as of March 2024. In an interview, S3 said that there were two residents with rashes (R2 and R5). In an interview, Barry said R1, R3, R4, and R5 were not diagnosed with scabies, and either had rashes of unknown origin or were being treated with permethrin as a precaution.

The department has determined the following as it relates to the allegations that staff do not follow infection control protocols, that staff are not addressing a scabies outbreak, and that staff did not report a scabies outbreak as required:

Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Sections 87470(b)(2)(A), 87470(b)(2), and 87470(b)(2)(B). An exit interview was held with Barry. Appeal rights and a copy of this report were left with Barry.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240220140418
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87470(b)(2)(A)
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"(A) The licensee shall consult with a medical professional, local health official, health department, or other research-based medical authority to determine the type of PPE to be used based on the contagious disease present in the facility."
This requirement was not met as evidenced by:
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Licensee agrees to contact public health by POC due date for guidance on PPE use, and other guidance as required by Title 22.
Licensee shall include LPA Moleski in correspondence with public health.
vincent.moleski@dss.ca.gov
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Based in interview, Barry admitted not having contacted public health or other like public health authority for guidance on the use of PPE, which poses an immediate health and safety risk.
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Type A
04/16/2024
Section Cited
CCR
87470(b)(2)
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" (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection."
This requirement was not met as evidenced by:
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Licensee agrees to immediately implement the use of gowns when caring for R2. Licensee shall provide photos of PPE stations to LPA Moleski by POC due date.
vincent.moleski@dss.ca.gov
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Based on observation, S2 and S3 were not wearing gowns, which are appropriate to prevent the spread of scabies, which poses an immediate health and safety risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240220140418
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87470(b)(2)(B)
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" (B) PPE shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the assisting with direct care for each resident."
This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding the proper use of PPE by POC due date. Licensee shall provide LPA Moleski a copy of the staff sign-in sheet.
vincent.moleski@dss.ca.gov
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Based on observation, staff members discarded used PPE in uncovered waste receptacles, which pose an immediate health and safety risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5