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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 07/01/2024
Date Signed: 09/05/2024 12:04:09 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
12/04/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231204145833
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: 83DATE:
07/01/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Danielle BarryTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident fell sustaining a fractures due to staff neglect
Staff did not seek medical attention for resident
Staff did not notify resident's authorized representative of incident
Staff are not meeting resident's hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review.

According to facility notes, incident reports, and medical records, a resident (R1) suffered numerous falls at this facility between 9/10/18 and 11/10/23. Falls documented during this time period include the following: On 9/10/18, R1 fell while family members were visiting. On 5/21/20, R1 fell on their right hand, and swelling and bruising were observed. R1’s physician was notified. On 6/22/23, R1 suffered an unwitnessed fall and complained of knee pain. R1 was sent to the hospital and R1’s physician was notified.

[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: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
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 7
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
12/04/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231204145833

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: 83DATE:
07/01/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Danielle BarryTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Staff are not meeting resident's diapering needs resulting sores
Staff made inapprorpiate comments towards resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit.

This investigation consisted of interviews, observation and record review.

LPA Moleski interviewed a resident (R1). R1 appeared clean and healthy. R1 said R1 loved the facility, and loved the staff of the facility. R1 said staff keep her clean and assist with toileting needs. R1 reported no concerns regarding her treatment at the facility or regarding staff conduct.

LPA Moleski interviewed eight staff members (S1-S8). None of the staff members interviewed were able to corroborate an allegation that S8 had made inappropriate comments toward R1. S8 denied ever having made inappropriate comments to R1. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20231204145833
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: 07/01/2024
NARRATIVE
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LPA Moleski reviewed R1’s file and other medical records and observed no indication that R1 had ever suffered from bed sores or diaper rashes. None of the staff members interviewed reported having observed bed sores or diaper rashes on R1. Multiple staff interviews indicated that R1 is able to notify staff when toileting assistance is needed. LPA Moleski reviewed a fax dated 3/14/23 sent from facility staff to R1’s physician which described a fungal infection observed on R1’s anus. LPA Moleski interviewed the author of the fax, S5, who said that the infection resolved shortly after receiving cream prescribed by R1’s physician. S5 had not observed any bed sores or diaper rashes present on R1.

The department has determined the following as it relates to the allegations that staff are not meeting a resident’s diapering needs, resulting in sores, and that staff made inappropriate comments toward a resident:

Based on record review, the above allegations are 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.

No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Barry.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20231204145833
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: 07/01/2024
NARRATIVE
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According to medical records, R1 was diagnosed with a fracture of the right kneecap and multiple fractures of the right side of the ribcage on 6/22/23. R1 underwent surgery on 6/24/23 to address this injury. R1 was sent to a rehabilitation center and returned to this facility on 7/15/23.

On 7/18/23, R1’s home health nurse noted that a surgical wound on R1’s knee appeared to be infected, and instructed staff to send R1 to the hospital if the wound became redder in coloration. A fax was sent by facility staff to R1’s physician on the same day, stating that if the condition of the wound worsened, R1 would be sent out. According to facility notes, on 7/19/23, R1 fell, opening the pre-existing wound on their knee. A facility staff member cleaned and bandaged the wound, but R1 was not sent to the hospital until the next day, 7/20/23. No documentation exists that R1’s physician was notified when the fall occurred, and no documentation exists to show that R1’s responsible party (RP) was notified. In an interview, R1’s RP said that they were not notified after the incident.

On 8/15/23, R1 suffered an unwitnessed fall. R1 was taken to the hospital and R1’s physician was notified. According to medical records, R1 was diagnosed with a fracture to the right kneecap on 9/4/23. An incident report dated 9/4/23 states that R1 fell onto their knees at the facility. R1 was taken to the hospital, and R1’s physician was notified. On 9/21/23, staff note that R1 had returned from their last hospital visit, and note that staff must make sure R1 does not fall again. On 10/29/23, R1 suffered an unwitnessed fall and was placed back into bed. On 10/30/23, R1 suffered an unwitnessed fall. R1’s physician was notified.¬¬ On 11/10/23, R1 suffered an unwitnessed fall. R1’s physician was notified. The Community Care Licensing Division (CCLD) received only two incident reports regarding any the above incidents: one, dated 8/15/23, and another, dated 9/4/23.

Despite the number of falls suffered by R1 between 9/10/18 and 11/10/23, R1 did not receive an updated needs and services plan to address R1’s fall risk. R1’s most recent needs and services plan was dated 11/17/19 at the time this complaint investigation was opened. Interviews with current and former staff show that staff were aware R1 was a fall risk and that they were told to watch R1 closer, but were not asked to implement fall prevention measures, and no fall prevention plan was in place.

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

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20231204145833
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: 07/01/2024
NARRATIVE
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LPA Moleski interviewed eight staff members (S1-S8) regarding R1’s hygiene care. S1 said a podiatrist trims residents’ toenails about once every two months. S3 was not sure who is responsible for trimming residents’ nails. S4 said R1’s RP cuts R1’s toenails, and also that a podiatrist is responsible for trimming residents’ toenails, but did not know how often the podiatrist comes. S5 said they had observed R1 with long, unkempt toenails twice, once around June 2023 and once around August 2023. S5 said that they raised concerns to management about the situation, but nothing was documented. S6 said that they were not sure who was responsible for trimming R1’s nails, and said they had observed R1’s nails long on one occasion, around fall 2023. S8 said they had seen many residents with long and unkempt nails, and said R1 was likely one of them. S8 said residents must be added to a special list to receive nail trimming services, and said the podiatrist will visit about once every two months. S8 said that R1’s hair was also sometimes dirty. R1’s RP said they had observed R1 with long and unkempt nails previously.

The department has determined the following as it relates to the allegations that a resident fell sustaining fractures due to staff neglect, that staff did not seek medical attention for a resident, that staff did not notify a resident’s authorized representative of an incident, and that staff are not meeting a resident’s hygiene needs:

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 hereby cited per 22 CCR Sections 87468.1(a)(2), 87465(g), 87211(a)(1)(B), and 87464(f)(4). An exit interview was held with Barry. Appeal rights and a copy of this report were left with Barry.

This report was amended on 9/5/24 to include the following: A civil penalty in the amount of $500 is hereby assessed due to a violation resulting in injury to a resident, as described above. Additional civil penalties are currently being evaluated by the Department, pursuant to Health and Safety Code § 1569.49(f). An exit interview was held with Barry. Appeal rights, a copy of the civil penalty assessment, and a copy of this amended 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: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20231204145833
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: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2024
Section Cited
CCR
87468.1(a)(2)
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“Residents in all residential care facilities for the elderly shall have all of the following personal rights: … To be accorded safe, [and] healthful … accommodations…” This requirement was not met as evidenced by:
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Licensee agrees to develop a written fall prevention plan for R1 by POC due date.
Vincent.moleski@dss.ca.gov
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Based on interviews and record review, no fall prevention plan was developed or implemented for R1, despite suffering numerous falls between 9/10/18 and 11/10/23, which poses an immediate health, safety, and/or personal rights risk.
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Type A
07/02/2024
Section Cited
CCR
87465(g)
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“(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…” This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding injury response procedures and will send LPA Moleski an agenda of training topics by POC due date and a sign in sheet after completion.
Vincent.moleski@dss.ca.gov
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Based on interviews and record review, R1 physician was not notified after suffering a fall on 7/19/23 which re-opened a surgical wound, and immediate professional medical attention was not provided for this wound, which poses an immediate health, safety, and/or personal rights 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: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20231204145833
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: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2024
Section Cited
CCR
87211(a)(1)(B)
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“(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below....
(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.” This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding reporting requirements and will send LPA Moleski an agenda of training topics by POC due date and a sign in sheet after completion.
Vincent.moleski@dss.ca.gov
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Based on interviews and record review, R1’s RP was not notified after R1 suffered a fall on 7/19/23, and an incident report was not submitted to licensing, which poses a potential health, safety, and/or personal rights risk.
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Type B
07/15/2024
Section Cited
CCR
87464(f)(4)
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“(f) Basic services shall at a minimum include: … (4) Personal assistance and care as needed by the resident…” This requirement was not met as evidenced by:
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Licensee agrees to provide a written plan regarding nail care and podiatry care by POC due date.
Vincent.moleski@dss.ca.gov
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Based on interviews, sufficient personal assistance and care with regard to nail care was not provided to R1, which poses a potential health, safety, and/or personal rights 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: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7