347005361-1-3-2022-27-AS-KHOS-CD9HGZ-20220407061156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 12/23/2021
Date Signed: 01/03/2022 11:38:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2021 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211209123723

FACILITY NAME:	SUMMERSET ASSISTED LIVING		FACILITY NUMBER:	347005361
ADMINISTRATOR:	BEASLEY, CARLIE		FACILITY TYPE:	740
ADDRESS:	2341 VEHICLE DR		TELEPHONE:	(916) 330-1300
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95670
CAPACITY:	135	CENSUS:	DATE:	12/23/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Carlie Beasley, Administrator		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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Other: Facility is not following COVID-19 guidelines.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould, Licensing Program Manager (LPM) Czarrina Camilon Lee and Regional Manager (RM) Krystall Moore conducted a Tele-Inspection for Summerset Assisted Living on 12/23/21 at 3:30pm to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the observations of LPA Tung and statements obtained from Facility Administrator during the investigation process, the allegation has been corroborated. LPA Tung observed staff not wearing appropriate PPE on an unannounced inspection on 12/13/21. Facility Administrator also acknowledged the facility was not in compliance with public health orders from Provider Information Notice (PIN) 21-44 which requires staff to be vaccinated, obtain an exemption to be kept on file and to have non-vacinated staff test weekly.

Report continued on LIC 9099-C. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20211209123723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Other is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20211209123723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HSC 1569.50(a)(3)	1 2 3 4 5 6 7	On 12/13/21, administrator failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that facility staff failed to wear face coverings while working in the	1 2 3 4 5 6 7	Facility must be in compliance with COVID 19 Public Health orders by the POC due date and submit a written plan to ensure the facility is in compliance with public health orders and ensure all staff are wearing appropriate PPE at all times in the facility.
	8 9 10 11 12 13 14	licensed facility, in violation of official government orders requiring the wearing of face coverings while working under specified conditions. This requirement was not met as evidenced by LPA Tung observing several staff members without appropriate PPE which poses an immediate health, safety and personal rights risk for residents in care.	8 9 10 11 12 13 14
Type A 12/24/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This Requirement was not met as evidenced by statements obtained from Administrator stating the facility does not maintain a record of staff vaccination	1 2 3 4 5 6 7	Facility must be in compliance with COVID 19 Public Health orders by the POC due date and submit to the department documentation of staff vaccination exemptions and a written plan stating how the facility plans to obtain compliance with testing of unvaccinated staff and obtain staff vaccination exemptions.
	8 9 10 11 12 13 14	exemptions and has not met requirements for testing unvaccinated staff members which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3