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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 08/21/2024
Date Signed: 08/21/2024 04:07:09 PM


Document Has Been Signed on 08/21/2024 04:07 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SUMMERSET ASSISTED LIVINGFACILITY NUMBER:
347005361
ADMINISTRATOR:DANIELLE BARRYFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:135CENSUS: 85DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Danielle BarryTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 8/21/24 at 9:30am. License Fees were sent to Community Care Licensing (CCL) prior to todays visit.

LPA met with Danielle Barry, Executive Director and Terri Henry, Business Office Manager and stated the purpose of todays visit. Administrator certificate expires 6/5/26.
The facility is licensed for a capacity of 135 Non-ambulatory residents of which 20 maybe bedridden. Hospice Waiver approved for 25.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. There is 13 resident receiving hospice care services and 4 bedridden at this time. The most recent emergency drill was conducted on 8/1/24. LPA observed 2-day perishables and 7-day non-perishables. Facility utilizes a wander guard system for residents in need of more assistance. Facility has required postings which include Oxygen in Use.

The temperature thermostats inside was continuously observed to be at 72*F throughout the facility which is within the required range of 68-85*F. LPA obtained information that the facility houses 4 water heaters. The hot water temperature was measured between 106.5*F and 112.3*F in a random amount of rooms (135,139,217,303,308,310,327) which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and pull alarm system in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA reviewed 4 staff and 4 resident files during this visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/21/2024
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Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees-Submitted prior to todays visit
Criminal Record Clearances LIS536-Current
Administrative Organization LIC309-Current
Designation of Administrative Responsibility LIC308-Submit
Personnel Report LIC500-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-NA
Surety Bond LIC402-NA
Facility Floor Plan/Plot Plan LIC999-Current
Fire Clearance (consistent with terms and limitations of license)-NA
Qualifications of Administrator/Facility Manager-Submit
Articles of Incorporation/Organization, Constitution and bylaws-NA
Partnership Agreement-NA
Control of Property-Submit
Emergency Disaster Plan LIC610-Submit
Plan of Operation (Restricted Health Care Plan)-NA
Admission Policies and Procedures-NA
Health Screening Report-Facility Personnel LIC503-NA
Bacteriological Analysis of Private Water Supply-NA
In-service Training Program-NA
Medication Procedures-NA
Transportation Procedures-NA
Job Description/Personnel Policies-NA
Exemptions/Waivers and Exceptions-Current
First aid/CPR certificates-Current
Liability Insurance-(if applicable)Submit
Infection Control Plan-Submit if applicable

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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