Inspection Reports for
Summerset Assisted Living
2341 VEHICLE DR, RANCHO CORDOVA, CA, 95670
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
66% occupied
Based on a December 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 89
Capacity: 135
Deficiencies: 0
Date: Dec 15, 2025
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff were not allowing residents to choose their own hospice agency.
Complaint Details
The complaint alleged that staff were not allowing residents to choose their own hospice agency. The investigation included file reviews and phone interviews with responsible parties. The allegation was found to be unfounded as no evidence supported the claim.
Findings
The allegation was determined to be unfounded after review of hospice resident files and interviews with responsible parties. No deficiencies were observed or cited during the visit.
Report Facts
Residents receiving hospice services: 10
Residents reviewed on 5/21/25: 14
Hospice agencies involved: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation visit and interviews. |
| Danielle Barry | Designated Facility Administrator/Executive Director | Named as administrator but no longer working at the facility during the visit. |
| Terri Henry | Designee | Facility representative who met with the Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 84
Capacity: 135
Deficiencies: 0
Date: Aug 29, 2025
Visit Reason
The visit was an unannounced one-year required annual inspection conducted by the Licensing Program Analyst to assess compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. The physical plant, safety systems, medication storage, emergency preparedness, and staff and resident files were all inspected and met required standards.
Report Facts
Hospice Waiver approved: 25
Non-ambulatory residents bedridden capacity: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Barry | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour and compliance discussion |
| Jason Lund | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
Inspection Report
Census: 84
Capacity: 135
Deficiencies: 0
Date: Jul 7, 2025
Visit Reason
The Licensing Program Analyst conducted an unannounced collateral visit to the facility to evaluate compliance and interview a client and their responsible party.
Findings
No deficiencies were cited during this unannounced collateral visit. An exit interview was held and a copy of the report was left with the facility administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Barry | Facility Administrator | Met with Licensing Program Analyst during the visit. |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced collateral visit. |
| Stephen Richardson | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 87
Capacity: 135
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
The visit was an unannounced case management inspection regarding a death report sent to Community Care Licensing on 2025-05-16.
Findings
No deficiencies were observed or cited during the visit. The Licensing Program Analyst reviewed documents related to the resident's condition and death and discussed best practices for reporting resident deaths.
Inspection Report
Complaint Investigation
Census: 87
Capacity: 135
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility was not allowing residents to get mail.
Complaint Details
The complaint was substantiated. The facility was found to have withheld residents' mail improperly, violating their personal rights. A training was scheduled to address the issue.
Findings
The allegation was substantiated. The investigation found that mail for residents in memory care was being withheld and stored until conservators could pick it up, which violated residents' personal rights. No other deficiencies were cited during the visit.
Deficiencies (1)
CCR 87468.2 Additional Personal Rights of Residents were violated when mail for residents in memory care was held until conservators could pick it up, posing a potential threat to residents' health, safety, and personal rights.
Report Facts
Census: 87
Total Capacity: 135
Plan of Correction Due Date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Evaluator | Conducted the complaint investigation and authored the report |
| Danielle Barry | Designated Facility Administrator/Executive Director | Met with Licensing Evaluator and acknowledged the findings |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 135
Deficiencies: 2
Date: Apr 17, 2025
Visit Reason
Unannounced inspection to follow up on a substantiated complaint investigation regarding allegations of resident neglect, failure to seek medical attention, failure to notify authorized representative, and unmet hygiene needs.
Complaint Details
The complaint investigation was substantiated with findings that a resident fell sustaining fractures due to staff neglect, staff did not seek medical attention promptly, did not notify the resident’s authorized representative, and failed to meet the resident’s hygiene needs.
Findings
The facility was cited for violations related to personal rights, incidental medical and dental care, reporting requirements, and basic services. A civil penalty of $9,500 was assessed for serious bodily injury due to failure to provide an updated needs and services plan, resulting in multiple falls and fractures of a resident.
Deficiencies (2)
CCR 87468.1(a)(2) Personal Rights of Residents: The facility failed to protect a resident's personal rights, resulting in neglect and injury. CCR 87465(g) Incidental Medical and Dental Care: The facility did not seek timely medical attention after a resident's fall.
CCR 87211(a)(1)(B) Reporting Requirements: The facility failed to notify the resident’s authorized representative of the incident. CCR 87464(f)(4) Basic Services: The facility did not meet the resident’s hygiene needs.
Report Facts
Civil penalty amount: 9500
Civil penalty amount: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Barry | Administrator | Named in relation to failure to provide updated needs and services plan and cited violations. |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 135
Deficiencies: 0
Date: Feb 6, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not provide adequate hygiene care to a resident.
Complaint Details
The complaint alleged inadequate hygiene care to a resident, specifically poor general hygiene and skin breakdown on the resident's palms. The investigation included interviews with staff, the resident's conservator, and review of medical and care records. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
Based on interviews, observation, and record review, the allegation that staff did not provide adequate hygiene care to the resident was unsubstantiated. No deficiencies were cited and the resident's hygiene was observed to be adequate.
Report Facts
Facility Capacity: 135
Resident Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| Danielle Barry | Administrator | Facility administrator met during investigation and named in report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 135
Deficiencies: 1
Date: Jan 28, 2025
Visit Reason
The visit was an unannounced follow-up on a complaint investigation, during which an unrelated deficiency was also observed and addressed in this case management report.
Complaint Details
The visit was triggered by a complaint investigation. The deficiency related to the use of padded mittens without physician's orders was substantiated and cited.
Findings
A resident (R1) was found limited in the use of their hands by large padded mittens without a physician's order, violating 22 CCR Section 87608(a)(5). The facility was cited for this deficiency and required to submit a plan of correction.
Deficiencies (1)
22 CCR Section 87608(a)(5) was violated as a resident was limited in the use of their hands by large padded mittens. This poses an immediate health, safety, and personal rights risk.
Report Facts
Census: 94
Total Capacity: 135
Deficiency Type Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Barry | Facility Administrator | Met with Licensing Program Analyst and named in the deficiency discussion |
| Vincent Moleski | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not dispensing medications as prescribed and were falsifying resident records.
Complaint Details
The complaint alleged that facility staff were not dispensing medications as prescribed and were falsifying resident records. After investigation, the allegations were found to be unfounded, meaning they were false or without reasonable basis.
Findings
The investigation included interviews, medication cart audits, and review of medication records. No evidence was found to support the allegations, and the complaint was determined to be unfounded with no deficiencies cited.
Report Facts
Capacity: 135
Census: 95
Medication sample size: 6
Carestaff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Barry | Designated Facility Administrator/Executive Director | Met with Licensing Program Analyst during investigation |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 94
Capacity: 135
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced Case Management visit to verify staff employment status and compliance with exclusion orders.
Findings
No deficiencies were observed or cited during the visit. The facility was informed of an immediate exclusion order for a former staff member who is no longer employed at the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the Case Management visit and served the exclusion order. |
| Terri Henry | Business Office Manager | Met with Licensing Program Analyst during the visit and discussed staff employment. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 135
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that a resident sustained unexplained injuries while in care and that staff did not report the incident to the resident's responsible party.
Complaint Details
The complaint involved allegations that a resident sustained unexplained injuries and that staff failed to report the incident to the resident's responsible party. Both allegations were deemed unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident's medical records and facility reports showed no unexplained injuries, and the facility had attempted to notify the responsible party, leaving a message when contact was not made.
Report Facts
Capacity: 135
Census: 93
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation |
| Danielle Barry | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 135
Deficiencies: 0
Date: Sep 12, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff were not providing adequate supervision to reduce injuries, did not seek timely medical attention for a resident, and did not address the resident's skin issues promptly.
Complaint Details
The complaint involved allegations of inadequate supervision leading to resident injuries, delayed medical attention, and untimely response to skin issues. The investigation included interviews, record reviews, and observations. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that although the allegations were serious, there was insufficient evidence to substantiate the claims. The resident had multiple falls and skin issues, but the facility documented interventions and communication with hospice and responsible parties. No deficiencies were cited.
Report Facts
Resident falls: 3
Staff on shift: 4
Status checks: 4
Medication administration dates: 7
Inspection Report
Capacity: 135
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
The visit was an unannounced case management visit to deliver an Order to Licensee/Facility of Immediate Exclusion related to staff exclusions.
Findings
No deficiencies were observed or cited during the visit. The Licensing Program Analyst served exclusion orders to the facility representatives.
Inspection Report
Annual Inspection
Census: 85
Capacity: 135
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
The inspection was an unannounced Required - 1 Year visit to evaluate compliance with licensing regulations and ensure safety and proper operation of the facility.
Findings
No deficiencies were cited during this visit. The facility was found to be in compliance with regulations including safety measures, medication storage, emergency preparedness, and environmental conditions.
Report Facts
Hospice residents: 13
Bedridden residents: 4
Hospice waiver capacity: 25
Water heaters: 4
Perishables observed: 2
Non-perishables observed: 7
Staff files reviewed: 4
Resident files reviewed: 4
Inspection Report
Complaint Investigation
Census: 83
Capacity: 135
Deficiencies: 4
Date: Jul 1, 2024
Visit Reason
Unannounced complaint investigation visit triggered by allegations including resident falls with fractures due to staff neglect, failure to seek medical attention, failure to notify authorized representative, and inadequate hygiene care.
Complaint Details
The complaint investigation was substantiated for allegations that a resident fell sustaining fractures due to staff neglect, staff did not seek medical attention, and staff did not notify the resident's authorized representative of the incident. Allegations that staff were not meeting the resident's diapering needs resulting in sores and that staff made inappropriate comments toward the resident were unsubstantiated.
Findings
The investigation substantiated allegations that a resident suffered fractures due to staff neglect, medical attention was not timely sought, and the resident's authorized representative was not notified after an incident. The facility failed to implement a fall prevention plan and did not provide adequate hygiene care, including nail care. Other allegations regarding diapering needs and inappropriate staff comments were unsubstantiated.
Deficiencies (4)
22 CCR 87468.1(a)(2): No fall prevention plan was developed or implemented for a resident despite numerous falls between 9/10/18 and 11/10/23, posing an immediate health and safety risk.
22 CCR 87465(g): Resident's physician was not notified after a fall on 7/19/23 which reopened a surgical wound, and immediate medical attention was not provided, posing an immediate health and safety risk.
22 CCR 87211(a)(1)(B): Resident's responsible party was not notified after a fall on 7/19/23, and an incident report was not submitted to licensing, posing a potential health and safety risk.
22 CCR 87464(f)(4): Sufficient personal assistance and care with regard to nail care was not provided to a resident, posing a potential health and safety risk.
Report Facts
Civil penalty amount: 500
Capacity: 135
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Danielle Barry | Facility Administrator | Met with Licensing Program Analyst during investigation and exit interview. |
| Elisa Weathers | Administrator | Named as facility administrator in report header. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 135
Deficiencies: 5
Date: Jun 21, 2024
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations regarding resident room cleanliness, call button functionality, infection control practices, development of a stage 3 pressure injury, and retention of a resident with a prohibited health condition.
Complaint Details
The complaint investigation was substantiated. Allegations included unclean resident rooms, lack of working call buttons, poor infection control, development of a stage 3 pressure injury due to delayed medical assessment, and retention of a resident with a prohibited health condition. Civil penalties of $500 were assessed with potential for additional penalties.
Findings
The investigation substantiated multiple allegations including unclean resident rooms, lack of working call buttons for residents in memory care, inadequate infection control practices, failure to timely send a resident with a pressure injury for medical assessment resulting in a stage 3 pressure injury, and retention of a resident with a prohibited health condition.
Deficiencies (5)
CCR 87303(a): The facility was not clean and sanitary at all times, with housekeeping services missing on 3.5 days per week and 1 out of 3 resident rooms observed not clean.
CCR 87303(i)(1)(A): The facility did not provide call signal systems operating from each resident's living unit; residents lacked call pendants and call alerts in living spaces.
CCR 87470(2)(A): Environmental cleaning and disinfection activities were inadequate; restrooms in common areas were not cleaned and disinfected between resident use.
CCR 87615(a)(1): The facility retained a resident with a stage 3 pressure injury, a prohibited health condition under regulations.
CCR 87465(a)(1): The facility failed to arrange timely medical assessment and treatment for a resident's pressure injury, resulting in it becoming a stage 3 pressure injury.
Report Facts
Census: 83
Total Capacity: 135
Civil Penalty: 500
Memory Care Residents: 30
Housekeeping Coverage: 3.5
Resident Rooms Cleaned per Day: 10
Resident Rooms Cleaned per Day: 6
Care Staff on PM Shift: 2
Med Tech on PM Shift: 1
Days Delay to Hospital: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation visit |
| Danielle Barry | Designated Facility Administrator | Met with Licensing Program Analyst during investigation |
| Stephen Richardson | Supervisor | Supervisor overseeing the investigation |
| S4 | Memory Care Director | Provided information about care practices and pressure injury protocols |
| S1 | Staff who observed pressure injury and believed resident should have been sent to hospital earlier |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 135
Deficiencies: 0
Date: Apr 24, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff handled a resident in a rough manner.
Complaint Details
The complaint alleged that a male staff member kicked a resident's knees out to get the resident to sit on a toilet. Interviews with staff, the resident's responsible party, and a hospice nurse found no evidence to substantiate the allegation.
Findings
Based on interviews, observation, and record review, the allegation that staff handled a resident roughly was unsubstantiated. No deficiencies were cited regarding this allegation.
Report Facts
Capacity: 135
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| Danielle Barry | Facility Administrator | Met with the evaluator during the investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 135
Deficiencies: 3
Date: Apr 15, 2024
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations that staff do not follow infection control protocols, are not addressing a scabies outbreak, and did not report the outbreak as required.
Complaint Details
The complaint was substantiated. The investigation found that staff failed to follow infection control protocols, did not properly address a scabies outbreak, and failed to report the outbreak as required by regulations.
Findings
The investigation substantiated the allegations based on interviews, observations, and record review. Staff were observed not wearing appropriate PPE such as gowns and masks, and used PPE was discarded improperly in uncovered trash receptacles, posing immediate health and safety risks.
Deficiencies (3)
CCR 87470(b)(2)(A): The licensee failed to consult with public health or a medical authority to determine appropriate PPE use for the contagious disease present in the facility. The administrator admitted not contacting public health, posing an immediate health and safety risk.
CCR 87470(b)(2): Staff and volunteers providing direct care to residents with contagious disease did not wear appropriate PPE such as gowns, increasing risk of infection spread.
CCR 87470(b)(2)(B): Staff discarded used PPE in uncovered waste receptacles, which poses an immediate health and safety risk.
Report Facts
Capacity: 135
Census: 86
Plan of Correction Due Date: Apr 16, 2024
Inspection Report
Complaint Investigation
Census: 86
Capacity: 135
Deficiencies: 1
Date: Mar 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that a resident received an unlawful eviction notice.
Complaint Details
The complaint allegation that a resident was served an unlawful eviction notice was substantiated based on a preponderance of evidence. The facility failed to include required information in the eviction notice as mandated by regulation.
Findings
The allegation was substantiated based on record review. The facility served a resident an unlawful eviction notice that did not comply with required regulations, lacking specific facts and required statements. The facility was cited for violating 22 CCR Section 87224(d).
Deficiencies (1)
22 CCR Section 87224(d) was violated because the eviction notice did not include specific facts to permit determination of the date, place, witnesses, and circumstances concerning the reasons for eviction. The resident was served an unlawful eviction notice posing a potential health, safety, and personal rights risk.
Report Facts
Capacity: 135
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Evaluator | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Monitoring
Census: 87
Capacity: 135
Deficiencies: 1
Date: Feb 21, 2024
Visit Reason
The visit was an unannounced case management monitoring visit conducted to review compliance with licensing requirements, specifically regarding staff association with the facility roster.
Findings
The facility was cited for having an individual, Danielle Barry, present and working without being properly associated with the facility roster as required by regulation. A civil penalty was assessed for four days of non-compliance.
Deficiencies (1)
CCR 87355(e)(2): The facility failed to associate Danielle Barry through Guardian or submit appropriate transfer documents prior to her working at the facility, posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 400
Days unassociated: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Barry | Named in deficiency for being present and working without proper association to the facility roster. | |
| Vincent Moleski | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Stephen Richardson | Supervisor named in the report. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 135
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not ensure a resident received assistance with a wheelchair and was not brought down for meal service.
Complaint Details
The complaint alleged that staff did not ensure a resident received assistance with a wheelchair and was not brought down for meal service. The investigation found these allegations unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews, observation, and record review. The allegations were found to be unsubstantiated based on evidence gathered, including resident and staff interviews and observations. No deficiencies were cited during this visit.
Report Facts
Capacity: 135
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| Elisa Weathers | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 135
Deficiencies: 2
Date: Feb 1, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations regarding insufficient staffing to meet resident care needs and failure to provide timely bathing services.
Complaint Details
The complaint investigation was substantiated for allegations that the licensee did not ensure sufficient staffing and that residents did not receive bathing services in a timely manner. The allegation that staff did not ensure memory care residents were checked every two hours was unsubstantiated.
Findings
The investigation substantiated that the facility did not have sufficient staffing to meet resident needs and that bathing services were not provided as scheduled or as needed. Another allegation regarding two-hour checks on memory care residents was unsubstantiated.
Deficiencies (2)
CCR 87411(a) staffing was not sufficient to meet the needs of residents, posing an immediate health, safety, and personal rights risk.
CCR 87464(f)(4) bathing services were not provided as needed or as indicated on resident assessments, posing an immediate health, safety, and personal rights risk.
Report Facts
Capacity: 135
Census: 85
Residents in memory care: 32
Residents in assisted living: 52
Inspection Report
Annual Inspection
Census: 89
Capacity: 135
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate compliance with Title 22 regulations at the assisted living facility.
Findings
The facility was found to be clean, odor-free, and in good repair with proper furnishings and safety equipment. No deficiencies were observed during the inspection.
Report Facts
Water temperature readings: 113
Water temperature readings: 117.1
Water temperature readings: 115.2
Water temperature readings: 118.1
Fire extinguisher last serviced: Jul 11, 2023
Last fire drill date: Mar 7, 2023
Resident files reviewed: 10
Staff files reviewed: 10
Medication administration records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pang Lee | Licensing Program Analyst | Conducted the inspection and evaluation |
| Elisa Weathers | Administrator | Facility administrator who assisted with the inspection |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 135
Deficiencies: 1
Date: Oct 3, 2022
Visit Reason
Unannounced complaint investigation visit to Summerset Assisted Living Facility to investigate multiple allegations including resident injury from a fall, grooming and hygiene neglect, room maintenance issues, improper charges, and mishandling of personal belongings.
Complaint Details
The complaint investigation was initiated based on allegations received on 06/02/2022. The investigation found the allegations of injury from a fall, grooming and hygiene neglect, room maintenance, and improper charges unsubstantiated. The allegation of mishandling personal belongings was substantiated. The report states the findings may be amended if additional information is received.
Findings
Most allegations including injury from a fall, grooming and hygiene neglect, room maintenance, and improper charges were unsubstantiated due to lack of corroborating evidence. However, the allegation of mishandling a resident's personal belongings was substantiated as items were missing and the facility reimbursed the family. The facility lacked documentation of a theft/loss program review.
Deficiencies (1)
CCR 87468.2(a)(25): Facility failed to protect resident property from theft or loss as evidenced by missing clothing and items which were not maintained, posing a potential health, safety, and personal rights risk.
Report Facts
Capacity: 135
Census: 106
Deficiency count: 1
Plan of Correction Due Date: Oct 21, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Carlie Beasley | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 103
Capacity: 135
Deficiencies: 1
Date: Jun 23, 2022
Visit Reason
An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations, including a physical plant inspection and review of resident and employee files.
Findings
The facility was generally sanitary with adequate food supply and proper COVID-19 precautions. One staff file was incomplete but corrected during the visit. A technical violation advisory was issued for unlocked cleaning supplies accessible to residents with dementia, posing an immediate health and safety risk.
Deficiencies (1)
87705(f)(2) Care of Persons with Dementia: Toxic substances including cleaning supplies were accessible to dementia residents on the second floor, posing an immediate health and safety risk.
Report Facts
Residents present: 103
Licensed capacity: 135
Hospice residents: 10
Water temperatures: 105
Water temperatures: 108
Water temperatures: 115
Inspection Report
Complaint Investigation
Census: 115
Capacity: 135
Deficiencies: 0
Date: Mar 28, 2022
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations of neglect and lack of supervision at Summerset Assisted Living Facility.
Complaint Details
The complaint alleged insufficient staff to meet residents' needs and inappropriate care and supervision. The investigation found no evidence to substantiate these allegations. The complaint was determined unsubstantiated but may be amended if new information arises.
Findings
The allegations of neglect and lack of supervision were found to be unsubstantiated based on interviews, observations, and documentation. Staff were observed to be adequate in number and knowledgeable, and residents' needs appeared to be met.
Report Facts
Capacity: 135
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Carlie Beasley | Administrator | Facility administrator named in report header |
| Elisa Weathers | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Routine
Capacity: 135
Deficiencies: 0
Date: Dec 28, 2021
Visit Reason
The inspection was a tele-inspection conducted to evaluate the facility's infection control measures related to COVID-19, including screening processes for staff and visitors and PPE evaluation.
Findings
The inspection found that infection control measures were being followed, including staff screening and PPE use. No deficiencies were cited under California Code of Regulations, TITLE 22.
Inspection Report
Plan of Correction
Capacity: 135
Deficiencies: 0
Date: Dec 27, 2021
Visit Reason
An unannounced Plan of Correction (POC) inspection was conducted to ensure the facility is addressing and correcting deficiencies cited on 12/23/21 and to deliver 320 N95 masks to the facility.
Findings
No deficiencies were cited during this inspection. The facility was observed to be in compliance with public health orders, with staff wearing appropriate masks and PPE supplies available. A follow-up POC inspection will be conducted to ensure all citations have been corrected.
Report Facts
N95 masks delivered: 320
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and discussed corrections with the Administrator |
| Carlie Beasley | Administrator | Facility Administrator who discussed corrections and steps for compliance |
Inspection Report
Monitoring
Capacity: 135
Deficiencies: 1
Date: Dec 23, 2021
Visit Reason
The tele-inspection was conducted by CDPH and Health Facility Evaluation Nurses to evaluate infection control measures in place due to new COVID-19 positive residents in memory care and Assisted Living units.
Findings
The inspection reviewed staff and visitor screening, testing protocols, group activities, communal dining, and PPE availability. The facility was found non-compliant with Public Health orders regarding staff testing and vaccination exemptions.
Deficiencies (1)
CCR 87405(d)(2): The administrator did not meet the requirement of knowledge and ability to conform to applicable laws and regulations, evidenced by non-compliance with Department regulations and Public Health orders including staff testing and vaccination exemptions.
Report Facts
Total Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carlie Beasley | Administrator | Named as facility administrator and participant in inspection |
Inspection Report
Complaint Investigation
Capacity: 135
Deficiencies: 2
Date: Dec 23, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that the facility was not following COVID-19 guidelines.
Complaint Details
The complaint was substantiated. The facility was found not following COVID-19 guidelines, including staff not wearing PPE and failure to comply with vaccination and testing requirements.
Findings
The allegation was substantiated based on observations and statements that staff were not wearing appropriate PPE and the facility was not in compliance with public health orders regarding staff vaccination and testing.
Deficiencies (2)
HSC 1569.50(a)(3): Administrator failed to protect clients' personal rights and safety as staff did not wear face coverings while working, violating government orders and posing immediate health and safety risks.
CCR 87468.1(a)(2): Facility did not maintain records of staff vaccination exemptions and failed to meet testing requirements for unvaccinated staff, posing immediate health and safety risks to residents.
Report Facts
Facility Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carlie Beasley | Administrator | Named in relation to findings about failure to ensure staff compliance with PPE and vaccination/testing requirements |
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation |
| Czarrina Camilon Lee | Licensing Program Manager | Supervised the complaint investigation |
Inspection Report
Capacity: 135
Deficiencies: 0
Date: Aug 16, 2021
Visit Reason
The Department conducted an office meeting via Microsoft Teams to address concerns the facility had with Provider Information Notices (PINs) related to COVID-19 mitigation in residential facilities, specifically discussing updated staff testing and masking guidance.
Findings
The Regional Manager addressed facility questions regarding staff testing, vaccination mandates, supplemental staffing, and resident testing requirements, providing updated guidance and outlining the facility's responsibility to comply with COVID mitigation measures.
Inspection Report
Annual Inspection
Census: 117
Capacity: 135
Deficiencies: 0
Date: Aug 2, 2021
Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the health and safety of residents at Summerset Assisted Living.
Findings
The facility was found to be clean, odor-free, and in good repair with all required furniture and safety equipment in place. No deficiencies were cited during the inspection.
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