347005361-8-3-2023-27-AS-PLEE-CUCU9Q-20230803152331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:23:37 PM

Document Has Been Signed on 08/03/2023 03:23 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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: 89	DATE:	08/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:01 AM
MET WITH:	Elisa Weathers		TIME COMPLETED:	03:30 PM

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

On 08/03/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with receptionist , Colton Trotter, who then called the executive director to informed that CCLD is at the facility. Administrator, Elisa Weathers arrived approximately 35 minutes after. LPA Lee explained to administrator the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 6057652740 and will expire on 10/28/2024.

The facility is licensed for 115 non-ambulatory residents, 55 dementia residents, 20 bedridden residents, and 25 hospice residents. The census is 89 residents with 9 hospice residents. At 9:30 AM, LPA Lee and administrator toured the facility. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed resident bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed sufficient seven day non-perishable and two-way perishable food supplies. Water temperature was inspected in four residents rooms. Water temperatures was read as follow: 113.0, 117.1, 115.2 and 118.1 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 07/11/2023. The last fire drill was conducted on 03/07/2023. LPA Lee observed the facility has public telephones in the computer room, lobby and receptionist area. The facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 73 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 5 medication administration record (MAR) and it was complete. First aid kit was checked and is complete. LPA Lee requested residents and staff files for review.

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUMMERSET ASSISTED LIVING	FACILITY NUMBER: 347005361
	VISIT DATE: 08/03/2023

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
26
27
28
29
30
31
32

LPA Lee reviewed 10 resident files and 10 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents was given to LPA Lee during today's visit:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2