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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 12/28/2021
Date Signed: 12/31/2021 11:46:25 AM

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:
12/28/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carlie BeasleyTIME COMPLETED:
11:00 AM
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On 12/28/21 at 10:00 am Licensing Program Analyst (LPA) Kevin Gould and Licensing Program Manager (LPM) Czarrina Camilon-Lee and Regional Manager Krystall Moore conducted a tele-inspection with Summerset Assisted Living. Also joining the meeting Health Facility Evaluation Nurses (HFENs) Toni River and Roxane Fangon.

Attending this meeting on behalf of Summerset Assisted Living are: Administrator Carlie Beasley

The purpose of the Tele-inspection is for HFENs to continue to evaluate the facility to ensure infection control measures are followed. during the inspection screening process for staff and visitors was observed and memory care PPE was evaluated. Administrator also toured the front entrance bathroom to ensure hand washing is available.

During this inspection the Department and facility representatives discussed the screening and testing of staff and staff vaccination exemption. Administrator informed department that all staff have been notified of the requirement to obtain vaccination or provide the facility with exemptions. Administrator informed the department that exemptions must be turned in by Friday 12/31/21 or would need to have first vaccine dose.

The department will continue to provide assistance with PPE and provide resources for scheduling a COVID booster clinic at the facility for residents and staff.

There are no deficiencies cited per California Code of Regulations, TITLE 22

Due to the inspection taking place via Microsoft Teams a copy of this report will be mailed to the facility for signature.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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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