347005361-4-24-2024-27-AS-SRIN-D5WNB8-20240604101842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 04/24/2024
Date Signed: 04/24/2024 03:51:15 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
02/20/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240220140418

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: 80	DATE:	04/24/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Danielle Barry		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.

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.

This investigation consisted of observation, interviews, and record review. During the course of this investigation, LPA Moleski interviewed eight staff members (S2-S9), a resident's responsible party (R1's RP), a hospice nurse (R1's RN), and a resident (R1).

During an interview, R1's RP claimed to have observed a male staff member kick R1's knees out from under R1 in order to get R1 to sit on a toilet.

During an interview, R1's hospice nurse said that they had not observed any such maneuvers being used at this facility, and had no suspicions of physical abuse committed by the staff. R1's hospice nurse said they had not observed any unusual or suspicious injuries on R1. [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: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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-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: 04/24/2024

NARRATIVE

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In interviews, staff members S2-S9 said they had not witnessed any such incident as described by R1's RP. Staff members S2-S9 said they had not seen other staff members handling R1 in a rough or abusive manner. All staff members interviewed described providing minimal assistance for R1's toilet use, such as verbal prompting and reminders.

In an interview, R1 said R1 liked the facility's staff, but was not able to answer follow up questions regarding how the staff have treated R1. LPA Moleski reviewed R1's file. LPA Moleski reviewed an LIC 602, dated 12/27/23. R1 has dementia, according to the LIC 602.

The department has determined the following as it relates to the allegation that staff handled a resident in a rough manner:

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

No deficiencies were cited regarding this allegation. 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: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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