<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 11/22/2024
Date Signed: 11/22/2024 11:17:44 AM

Document Has Been Signed on 11/22/2024 11:17 AM - 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/
DIRECTOR:
DANIELLE BARRYFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 135TOTAL ENROLLED CHILDREN: 0CENSUS: 94DATE:
11/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Terri HenryTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 11/22/2024 at 10:30am. LPA met with Terri Henry, Business Office Manager and stated the purpose of the visit. LPA inquired if staff #1 (S1) was presently on the premises during this visit. Terri Henry, Business Office Manager stated the staff does not work in the facility any longer. S1 last worked in the facility on 4/10/2023.

LPA was provided a copy of the payroll employment information document from Paychex Oasis that indicates that S1 was terminated on 4/10/2023 due to a violation of company policies.

LPA served notice of "ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY" for S1 who was not present at the time of visit. Terri Henry, Business Office Manager was advised an immediate removal is warranted and requested the Personnel Report (LIC500) and Guardian account be updated to remove S1 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL). LPA provided a copy of the most current Guardian roster during this visit.

LPA informed Terri Henry, Business Office Manager that S1 is not allowed to be employed and/or on any facility premises. The Order to Individual of Immediate Exclusion From All Facilities will be in effect as of 12/2/2024 upon receipt of the letter. A copy of the letter was given to the facility during this visit.

The facility understands this is an Immediate Exclusion and has agreed S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, A Copy of report given.
Stephen RichardsonTELEPHONE: (916) 263-4746
Victoria BrownTELEPHONE: (209) 814-1955
DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1