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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002613
Report Date: 05/30/2024
Date Signed: 05/30/2024 03:48:35 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20240529130731
FACILITY NAME:SUMMERFIELD SENIOR LIVINGFACILITY NUMBER:
515002613
ADMINISTRATOR:GILDEA, CHANTELFACILITY TYPE:
740
ADDRESS:1224 PLUMAS STREETTELEPHONE:
(530) 755-3850
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:99CENSUS: 62DATE:
05/30/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rebecca Ballantine, Wellness DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff did not prevent resident from inappropriately touching another resident.
INVESTIGATION FINDINGS:
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13
LPA Hiratsuka conducted this unannounced complaint visit. LPA interviewed staff and the resident in question.

Interviews indicate the resident who did the inappropriate touch had no previous incidents prior and has not since. The resident's doctor and responsible party were notified and there has been adjustments made to the resident. The resident who was touched stated staff would not have been able to prevent it and feels satisfied with how the facility staff has handled the incident. The resident who was touched stated they stay clear of the other one and feels safe at this facility.

Even though the incident occurred, the interviews indicate staff were not at fault. The facility staff followed facility protocol for protecting the resident and reporting requirements.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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 2
Control Number 59-AS-20240529130731
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUMMERFIELD SENIOR LIVING
FACILITY NUMBER: 515002613
VISIT DATE: 05/30/2024
NARRATIVE
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Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

no deficiencies cited
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2