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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 01/28/2025
Date Signed: 01/28/2025 03:16:45 PM

Document Has Been Signed on 01/28/2025 03:16 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/
DIRECTOR:		DANIELLE BARRYFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 135CENSUS: 94DATE:
01/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Danielle BarryTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a complaint investigation, but observed an unrelated deficiency to be addressed in this case management report. LPA Moleski met with facility administrator Danielle Barry and explained the purpose of the visit.

LPA Moleski attempted to interview a resident (R1) in their room, and observed R1 lying in bed, rocking back and forth, and chewing and sucking on large off-white padded mittens wrapped onto R1's wrists. R1 was not able to verbally respond to LPA Moleski.

In an interview, Barry said that R1 came back from a recent hospital visit with the mittens, which were meant to prevent R1 from biting and sucking on their own hands. In an interview, the facility's memory care director (S1) said R1 returned to this facility from a hospital visit on 1/13/25 with the mittens. S1 said that R1's conservator has authorized the use of the mittens. LPA Moleski asked for physician's orders for the use of the mittens. S1 said there were no physician's orders on file for the mittens. 22 CCR Section 87608(a)(3) states that "a written order from a physician indicating the need for the postural support shall be maintained in the resident’s record" and that "the licensing agency shall be authorized to require other additional documentation if needed to verify the order." However, 22 CCR Section 87608(a)(5) indicates that "under no circumstances shall postural supports include ... depriving, or limiting the use of a resident's hands..." LPA Moleski asked S1 if R1 was able to remove the padded mittens independently. S1 said that R1 has on occasion been able to remove the mittens by using their mouth to remove the fastener holding the bindings in place. 22 CCR Section 87608(a)(2) states that "postural supports shall be fastened or tied in a manner that permits quick release by the resident." This facility is hereby cited per 22 CCR Section 87608(a)(5). If this facility wishes to use these sorts of devices in the future, the facility administrator should provide a physician's order, written consent from the resident and/or responsible parties, and a written request for an exception to the facility's assigned LPA. 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: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2025 03:16 PM - It Cannot Be Edited


Created By: Vincent Moleski On 01/28/2025 at 12:30 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: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2025
Section Cited
CCR
87608(a)(5)

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"(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski with a written plan regarding the use of these supportive devices, either discontinuance or requesting an exception from CCLD by POC due date.
vincent.moleski@dss.ca.gov
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Based on interview and observation, a resident (R1) was limited in the use of their hands by large padded mittens, which poses an immediate health, safety, and/or personal rights 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: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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