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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005361
Report Date: 12/23/2021
Date Signed: 12/31/2021 11:45:38 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:
12/23/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Carlie BeasleyTIME COMPLETED:
07:00 PM
NARRATIVE
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On 12/23/21 at 3:30pm 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 from California Department of Public Health (CDPH): Shantala Ahanya and Health Facility Evaluation Nurses (HFENs) Toni River and Roxane Fangon.

Attending this meeting on behalf of Summerset Assisted Living are: Administrator Carlie Beasley, Licensee Rick Beasley, and Regional Director, Sabrina Boyle.

The purpose of the Tele-inspection was for CDPH and HFENs to evaluate the infection control in place at the facility as the facility has recorded new COVID positives residents in memory care and Assisted living units within the facility.

During this inspection the Department and facility representatives discussed the screening and testing of staff, visitor screening, group activities, communal dining, and PPE outlined in Provider information Notices and Public Health Orders. A walk through inspection was also conducted to ensure proper screening and PPE available at the facility.

Following this meeting the facility will provide the department with a daily line list for all staff and residents and provide the department with results from all staff and resident testing until the facility receives clearance from public Health.

An on site inspection and technical assistance with vaccination education for staff will be provided by CDPH.
Report Continued on LIC 809-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: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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 3
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: 12/23/2021
NARRATIVE
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The following deficiencies are cited per California Code of Regulations, TITLE 22.

A copy of this report and Appeal Rights will be mailed to the facility for signature.

Page 2 of 2
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2021
Section Cited

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Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable
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laws, rules and regulations. This requirement was not met as evidenced by the facilities non-compliance with Department regulations and Public Health orders including staff testing and obtaining staff vaccination exemptions.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3