347005361-2-6-2025-27-AS-SRIN-DEGT4J-20250305132400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:07:26 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
11/20/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20241120164437

FACILITY NAME:	SUMMERSET ASSISTED LIVING		FACILITY NUMBER:	347005361
ADMINISTRATOR:	DANIELLE BARRY		FACILITY TYPE:	740
ADDRESS:	2341 VEHICLE DR		TELEPHONE:	(916) 330-1300
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95670
CAPACITY:	135	CENSUS: 94	DATE:	02/06/2025
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Danielle Barry		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not provide adequate hygiene care to 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), a resident’s conservator, six staff members (S1-S6), and Barry.

LPA Moleski reviewed an incident reported dated 11/17/24 which described R1 as having a change of condition. R1 was off baseline, and the left side of their face was swelling, according to the report. R1 was sent to a hospital for further evaluation. Shortly after R1 was sent to the hospital, the Community Care Licensing Division (CCLD) received a report alleging R1’s general hygiene was poor, and in particular that R1 had dead skin and other skin breakdown on their palms. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20241120164437

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: 02/06/2025

NARRATIVE

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LPA Moleski reviewed ongoing communication log notes from the days immediately preceding R1’s hospital visit on 11/17/24. No notes were recorded regarding R1 between 11/14 and 11/16. LPA Moleski reviewed shower sheets for R1 for the month of November and observed three sheets dated from before R1 was sent out, dated 11/3, 11/6, and 11/13.

In an interview, S3, who provided care to R1 on the morning on 11/17, said that they had to try multiple times to get R1 up, and when they did get up, R1 was resistant to care. S3 said that R1 appeared clean and hygienic, and it looked as if the previous shift had showered R1. S3 said that they also personally cleaned R1 after getting R1 up using wet wipes, and also put lotion on R1. S3 said they observed a “rash” on R1’s hands, but they could not put lotion on R1’s hands because R1 would eat it off their hands. S3 said that they notified the medication technician on duty (S1) that R1 was off baseline.

LPA Moleski reviewed a home health referral for R1 dated 6/20/24. According to the referral, R1 had "very dry and leathery" skin, and R1 was experiencing "skin shedding." R1 was admitted to home health for "complex disease management/prevention of skin breakdown." LPA Moleski reviewed prescription orders written by R1’s nurse practitioner (NP) dated 10/28/24 for Aquaphor Blue. The NP diagnosed R1 with dry skin. LPA Moleski reviewed a visit report written by home health, dated 11/13/24. The reason for the visit was to conduct a skin assessment on R1. Home health staff instructed facility staff to continue monitoring R1’s hands and skin and to report any changes. LPA Moleski reviewed home health reports dated 11/7 and 11/4 with largely the same reason and result. The report on 11/4 noted "severe dryness" of R1’s skin. LPA Moleski reviewed a visit report from R1’s NP dated 11/4. R1’s NP noted dry skin on R1’s face and fingers. The NP wrote that staff had used the Aquaphor Blue on R1, but R1’s skin appeared more dry afterward. The note continued to say that R1 was sucking on their fingers frequently, making application of ointment to R1’s hands impossible. Multiple staff interviews suggested R1 has a persistent behavior which involves sucking and/or biting on their own hands, and sometimes on their clothing, causing dry skin.

S1, the medication technician who responded to S3’s summons when they observed R1 was off baseline, said that R1 was very sleeping on the morning of 11/17/24. S1 said that R1 had slept in their clothes from the night before, and was not changed before being sent out to the hospital, due to R1’s unusual sleepiness. S1 said that they did not notice any unusual odor from R1 that morning, and had not observed any general issues with regard to R1’s hygiene. [continued on 9099-C]

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20241120164437

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: 02/06/2025

NARRATIVE

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In an interview, R1’s conservator said they were aware of R1’s skin condition, and their habit of sucking on their hands, and had been working closely with staff to address it. R1’s conservator said they had zero concerns regarding R1’s care at this facility, and complemented facility staff for sending out R1 whenever issues are observed. None of the six staff members interviewed (S1-S6) reported observing R1 dirty or unhygienic at any time. LPA Moleski attempted to speak with R1, but R1 was not able to verbally respond to questioning. LPA Moleski observed R1’s skin, clothes, and bedding to be clean. LPA Moleski did not observe an odor from R1. R1 was still hospitalized during LPA Moleski’s initial visit on 11/25/24, and by the time of LPA Moleski’s meeting with R1 on 1/28/25, R1’s conservator and facility staff had acquired large, padded mittens meant to prevent R1 from sucking on or biting their own hands.

The department has determined the following as it relates to the allegation that staff did not provide adequate hygiene care to a resident.

Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which 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.

No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Barry.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC9099 (FAS) - (06/04)

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