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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 12/27/2021
Date Signed: 12/27/2021 05:07:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUMMERSET ASSISTED LIVINGFACILITY NUMBER:
347005361
ADMINISTRATOR:BEASLEY, CARLIEFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:135CENSUS: DATE:
12/27/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:`Victoria OlivarezTIME COMPLETED:
05:15 PM
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On 12/27/21 at 3:10pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection to ensure the facility is addressing and correcting deficiencies cited on 12/23/21 and to deliver 320 N95 masks to the facility.

LPA Gould arrived at the facility and was screened by front desk facility staff for COVID 19 and had temperature taken and recorded in the visitor log. LPA observed that other visitors were screened at the front desk and observed one visitor signing out of the log who was screen prior to entry. LPA attempted to meet with facility Administrator Carlie Beasley but were unable to meet as the Administrator was not at the facility at the time of inspection. LPA and Administrator met via facetime and together LPA and Administrator discussed corrections and steps the facility are taking to be in compliance with public health orders.

LPA and Administrator discussed the daily line list received on 12/27/21. LPA observed the line list is still incomplete and was missing COVID exemptions for unvaccinated staff. Administrator stated it would take approximately one week for the facility to have all exemptions received and on file for staff who remain unvaccinated. LPA inquired as to how the facility is notifying staff and asked the facility to accelerate their efforts to have all staff vaccinated or obtain an exemption. Administrator stated they are informing staff at the facility today and Administrator has informed department managers to notify the staff of the requirement. LPA again asked to accelerate the efforts and begin to reach out to staff at home or via email to inform them of the requirement. LPA Gould interviewed one staff member, S2 (see confidential names list, LIC 811 dated 12/27/21) who stated they were unaware of any changes or requirement to obtain an exemption if unvaccinated.

Report Continued on LIC 9099-C. Page 1 of 2.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SUMMERSET ASSISTED LIVING
FACILITY NUMBER: 347005361
VISIT DATE: 12/27/2021
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LPA Gould and S1 conducted a walk through of the facility together and LPA Gould observed the 1st and 3nd floor Assisted Living area including the dining room and activity spaces. All staff observed by LPA in the facility were observed wearing an appropriate surgical mask. LPA Gould and S1 also toured the memory care unit on the 2nd floor. LPA observed additional PPE outside the Memory Care entrance and observed PPE carts with full supplies outside of a COVID isolation room.

Due to time constraints during todays inspection, a follow up POC inspection will be conducted at a later date to ensure all citations have been corrected and the facility is in compliance with all public health orders. LPA Gould obtained a staff schedule for Assisted Living, Memory Care, Front Desk and Kitchen staff for interviews on a later date.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2