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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 11/06/2024
Date Signed: 11/06/2024 10:57:03 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
06/13/2024 and conducted by Evaluator Jason Lund
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240613163034
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: 93DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Danielle BarryTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care

Staff did not report incident to resident's responsible party
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Danielle Barry. and explained the reason for the visit. Census: 93
Resident sustained unexplained injuries while in care - LPA Lund reviewed facility records, Resident’s (R1) medical records and interviews with staff. Based on reviewed facility records, Resident’s (R1) medical records and interviews with staff. Unusual Incident/Injury Report (LIC624) dated 6/7/2024 that R1 was sent to Kaiser Roseville for evaluation and treatment on 6/3/2024. Kaiser Admission paperwork dated 6/3/2024 stated that R1 was admitted to the Emergency Room (ER). Hospital admission physical exam states note acute distress and R1’s appearance is well- developed. Report states no unexplained injuries to R1.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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 2
Control Number 27-AS-20240613163034
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: 11/06/2024
NARRATIVE
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Based on reviewed facility records, Resident’s (R1) medical records and interviews with staff, on the information provided, it was unclear if resident sustained unexplained injuries while in care, therefore the allegation was deemed UNSUBSTANTIATED.

Staff did not report incident to resident's responsible party - LPA Lund reviewed facility records, and interviews with staff. Based on reviewed facility records and interviews with staff. Unusual Incident/Injury Report (UIR-LIC624) dated 6/7/2024 that Resident (R1) was sent to Kaiser Roseville for evaluation and treatment on 6/3/2024. The UIR also indicates that the facility reported to the POA and Community Care Licensing (CCL). Facility records indicated that the facility called the POA on 6/3/2024 to notify the R1 was sent to Kaiser Roseville but the POA didn’t answer, so the facility left a message.

Based on reviewed facility records and interviews with staff, on the information provided, it was unclear if staff did not report incident to resident's responsible party, therefore the allegation was deemed UNSUBSTANTIATED.


As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated 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. Exit interview conducted and report left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
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