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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:54:20 PM

Document Has Been Signed on 02/21/2024 02:54 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 87DATE:
02/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Danielle BarryTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with Danielle Barry and explained the purpose of the visit.

LPA Moleski reviewed Guardian records and observed that Barry has not, to this date, been associated to this facility roster. Barry said she was at the facility on 2/16/24, 2/19/24, and 2/20/24, and was present today, 2/21/24.

This facility is being cited per 22 CCR Section 87355(e)(2). A civil penalty in the amount of $100 per day for the four days Barry was present without being associated to this facility was assessed, for a total of $400. An exit interview was held with Barry. Appeal rights and a copy of this report were left with Barry.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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 2
Document Has Been Signed on 02/21/2024 02:54 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/21/2024 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET ASSISTED LIVING
FACILITY NUMBER: 347005361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
87355(e)(2)

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"All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: ...
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ..."
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Licensee agrees to either associate Barry through Guardian or submit appropriate transfer documents to sacasctransferrequest@dss.ca.gov by the POC due date. Licensee shall send LPA Moleski a copy of the updated roster and/or cc LPA Moleski on the email to sacasctransferrequest.dss.ca.gov.
vincent.moleski@dss.ca.gov
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This requirement was not met as evidenced by: Based on review of Guardian records and interview with Barry, Barry was not associated before starting work at this facility, which poses an immediate health and safety 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 Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
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