Inspection Reports for
Summerset Lincoln Assisted Living and Memory Care

567 3RD STREET, LINCOLN, CA, 95648

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 3.2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

20% better than California average
California average: 4 deficiencies/year

Deficiencies per year

16 12 8 4 0
2021
2022
2023
2024
2025
2026

Occupancy

Latest occupancy rate 45% occupied

Based on a January 2026 inspection.

Occupancy rate over time

20% 40% 60% 80% 100% Apr 2021 Mar 2022 Jun 2023 Jan 2024 Dec 2024 Dec 2025 Jan 2026

Inspection Report

Annual Inspection
Census: 60 Capacity: 132 Deficiencies: 0 Date: Jan 21, 2026

Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing requirements and ensure the health and safety of residents.

Findings
The facility was found to be clean, well organized, and compliant with all health and safety regulations. No deficiencies were cited during the inspection.

Inspection Report

Complaint Investigation
Census: 64 Capacity: 132 Deficiencies: 0 Date: Dec 8, 2025

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations regarding staff response times, resident comfort, dignity, and retaliation at the facility.

Complaint Details
The complaint was unsubstantiated. Allegations included staff not responding timely to call buttons, not providing a comfortable environment, not treating the resident with dignity, and retaliating against the resident for filing a complaint. The investigation found no preponderance of evidence to prove violations.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff met care assistance requirements, the resident's environment was clean and comfortable, staff treated the resident with dignity, and no retaliation was found.

Report Facts
Capacity: 132 Census: 64 Call responses: 14 Call responses: 20

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the complaint investigation visit
Megan GallagherAdministratorFacility administrator met during the investigation

Inspection Report

Complaint Investigation
Census: 65 Capacity: 132 Deficiencies: 0 Date: Nov 5, 2025

Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff does not ensure residents are provided a safe environment.

Complaint Details
The complaint alleged that staff did not ensure residents were provided a safe environment. The investigation found the allegation to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.
Findings
The Licensing Program Analyst investigated the allegation by reviewing resident documentation, touring the facility, and conducting interviews. The allegation was found to be unfounded as the resident with behaviors received medical care and the behaviors are now well managed.

Employees mentioned
NameTitleContext
Bethany MirlohiLicensing Program AnalystConducted the complaint investigation and authored the report.
Megan GallagherAdministratorMet with the Licensing Program Analyst during the investigation and provided information about the resident's behaviors and care.

Inspection Report

Complaint Investigation
Census: 61 Capacity: 132 Deficiencies: 0 Date: Mar 6, 2025

Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff were falsifying residents' medication administration records and not ensuring medication was administered as prescribed.

Complaint Details
The complaint involved allegations that staff falsified medication administration records and failed to administer medications as prescribed. The investigation found inconsistencies between medication administration records and controlled drug records but no evidence of intentional or fraudulent actions. The complaint was unsubstantiated.
Findings
The investigation reviewed resident and facility records and conducted interviews but found insufficient evidence to substantiate the allegations. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Facility Capacity: 132 Resident Census: 61

Inspection Report

Complaint Investigation
Census: 61 Capacity: 132 Deficiencies: 0 Date: Mar 6, 2025

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-10-31 regarding staff response to resident pendant calls and toileting needs.

Complaint Details
The complaint was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found insufficient evidence to substantiate the allegations. Records and interviews did not support claims that pendant calls were not answered timely or that toileting needs were unmet.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the complaint investigation visit.
Megan GallagherAdministratorMet with investigator during the complaint investigation.

Inspection Report

Annual Inspection
Census: 58 Capacity: 132 Deficiencies: 0 Date: Feb 13, 2025

Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing requirements.

Findings
The inspection found no deficiencies. Resident and staff files contained all required paperwork and training. The facility was toured and no health or safety violations were observed.

Employees mentioned
NameTitleContext
Megan GallagherExecutive DirectorMet with during inspection and mentioned in report
Graham GunbyLicensing Program AnalystConducted the inspection
Troy OrdonezSupervisorNamed as supervisor in report

Inspection Report

Complaint Investigation
Census: 58 Capacity: 132 Deficiencies: 0 Date: Feb 12, 2025

Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-09-04 regarding medical attention delays, insufficient staffing, dietary needs not met, unlawful eviction, and staff training deficiencies.

Complaint Details
The complaint included allegations that staff did not provide timely medical attention, the facility had insufficient staff, staff did not meet dietary needs, unlawful eviction occurred, and staff were not properly trained. All allegations were found unsubstantiated or unfounded based on evidence reviewed.
Findings
The investigation found all allegations to be unsubstantiated or unfounded after review of records, interviews, and observations. The facility met regulatory requirements and no violations were confirmed.

Report Facts
Facility Capacity: 132 Resident Census: 58

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the complaint investigation and delivered findings
Megan GallagherAdministratorFacility administrator met during investigation and exit interview

Inspection Report

Complaint Investigation
Census: 64 Capacity: 132 Deficiencies: 1 Date: Dec 18, 2024

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-01-17 regarding alleged neglect and inadequate care at Summerset Lincoln Assisted Living and Memory Care.

Complaint Details
The complaint investigation was substantiated for failure to seek medical attention for a UTI and dehydration. Other allegations including neglect resulting in death, unsanitary room conditions, failure to provide services as promised, unmet hygiene needs, and rough handling were unsubstantiated.
Findings
The investigation substantiated that staff failed to seek timely medical attention for a resident with a UTI and dehydration, resulting in delayed care. Other allegations including neglect resulting in death, unsanitary room conditions, failure to provide promised services, unmet hygiene needs, and rough handling were found unsubstantiated.

Deficiencies (1)
CCR 87466: The licensee failed to ensure residents were regularly observed for changes in condition and that such changes were documented and reported to the resident's physician and responsible person. Facility staff delayed contacting the primary physician about a resident's declining health until six days after observation.
Report Facts
Facility Capacity: 132 Resident Census: 64 Plan of Correction Due Date: Dec 19, 2024

Employees mentioned
NameTitleContext
Graham GunbyLicensing EvaluatorConducted the complaint investigation and authored the report
Megan GallagherExecutive DirectorMet with Licensing Program Analysts during the investigation
Mark MorrisAdministratorFacility administrator listed in the report

Inspection Report

Complaint Investigation
Census: 66 Capacity: 132 Deficiencies: 2 Date: Sep 26, 2024

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-07-25 regarding resident supervision and billing practices at the facility.

Complaint Details
The complaint investigation was substantiated for allegations that a resident wandered away due to lack of care and supervision and that staff billed the resident for services not rendered. The allegation that staff did not keep the resident's authorized person informed of a change in health condition was unsubstantiated.
Findings
The investigation substantiated that a resident eloped due to lack of supervision and that the facility billed for services not rendered during that time. Another allegation regarding failure to keep the resident's authorized person informed was unsubstantiated.

Deficiencies (2)
CCR 87705(c)(4) Care of Persons with Dementia. The facility failed to ensure an adequate number of direct care staff to support residents' needs, evidenced by a resident eloping without staff knowledge, posing a direct threat to resident safety.
CCR 87507(f) Admission Agreements. The facility billed for care services not rendered between 7/8/2024 and 7/9/2024, including frequent checks and supervision for exit seeking, posing an indirect threat to resident safety.
Report Facts
Civil penalty: 500 Status checks per shift: 16 Monthly billing amount: 3000

Employees mentioned
NameTitleContext
Melissa ParksLicensing Program AnalystConducted the complaint investigation and authored the report.
Megan GallagherAdministratorFacility administrator met with the Licensing Program Analyst during the investigation.

Inspection Report

Complaint Investigation
Census: 66 Capacity: 132 Deficiencies: 0 Date: Sep 26, 2024

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-01-11 alleging unqualified staff providing care and supervision to diabetic residents, medication mishandling, and inadequate staff training among other concerns.

Complaint Details
The complaint was unsubstantiated. Allegations included unqualified staff providing care and supervision to diabetic residents, unqualified medication administration, mishandling of medical records and medications, failure to meet medical needs, improper disposal of expired medication, and inadequate staff training. The investigation found no preponderance of evidence to prove these violations occurred.
Findings
The investigation found no evidence to substantiate the allegations. Staff files showed required training was completed, medication handling followed proper procedures, and no unqualified staff were currently administering insulin. The complaint was determined to be unsubstantiated.

Report Facts
Capacity: 132 Census: 66

Employees mentioned
NameTitleContext
Melissa ParksLicensing Program AnalystConducted the complaint investigation
Megan GallagherAdministratorMet with Licensing Program Analyst during investigation

Inspection Report

Complaint Investigation
Census: 70 Capacity: 132 Deficiencies: 0 Date: Mar 11, 2024

Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not provide a comfortable and safe environment for residents and that the backup generator was not in working condition.

Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that during a city-wide power outage, the facility's portable generator was not functioning properly due to a burned-out fuse, which was promptly repaired. The facility followed its Emergency and Disaster Plan by renting a generator to supply power to common areas and residents, and the complaint was determined to be unsubstantiated.

Report Facts
Facility Capacity: 132 Resident Census: 70

Employees mentioned
NameTitleContext
Melissa ParksLicensing EvaluatorConducted the complaint investigation
Mark MorrisAdministratorFacility administrator interviewed during investigation

Inspection Report

Census: 68 Capacity: 132 Deficiencies: 0 Date: Feb 14, 2024

Visit Reason
An informal conference was conducted to discuss the high volume of complaints, inability to remain in substantial compliance with regulations, and specific incidents occurring in the last 12 months.

Findings
The facility has been cited 13 times in the last year for issues including care of persons with dementia, medication mismanagement, insufficient staffing, and other regulatory violations. No deficiencies were cited during this meeting.

Report Facts
Citations in last year: 13 Type A citations: 9 Type B citations: 4 Open complaints: 3

Employees mentioned
NameTitleContext
Mark MorrisAdministratorPresent at informal conference and facility representative
Maribeth SentyLicensing Program ManagerPresent at informal conference and supervisor
Melissa ParksLicensing Program AnalystPresent at informal conference and licensing evaluator
Rick BeasleyOwnerPresent at informal conference
Sabrina BoyleRegional ManagerPresent at informal conference

Inspection Report

Complaint Investigation
Census: 67 Capacity: 132 Deficiencies: 0 Date: Feb 6, 2024

Visit Reason
The visit was a case management inspection to obtain additional information on an incident reported to the Department on January 31, 2024.

Complaint Details
The investigation was related to an incident where a resident was observed attempting to clear their throat and later required the Heimlich Maneuver. The resident was pronounced deceased at the facility. No deficiencies were cited.
Findings
The Licensing Program Analyst discussed the incident involving a resident who was observed in distress and later pronounced deceased. No deficiencies were cited during the visit.

Employees mentioned
NameTitleContext
Melissa ParksLicensing Program AnalystConducted the case management visit and investigation.
Emily PinedoResident Services DirectorProvided information regarding the incident involving the resident.

Inspection Report

Annual Inspection
Census: 68 Capacity: 132 Deficiencies: 0 Date: Jan 29, 2024

Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing requirements.

Findings
The inspection found no health or safety violations. All resident and staff files contained the required paperwork and training. Emergency supplies and facility conditions met regulatory standards.

Inspection Report

Complaint Investigation
Census: 70 Capacity: 132 Deficiencies: 4 Date: Oct 10, 2023

Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2023-04-06 regarding multiple allegations including inadequate hygiene care, unqualified staff administering insulin, falsified medication records, and resident falls.

Complaint Details
The complaint investigation was substantiated for allegations of unqualified staff administering insulin and inadequate supervision leading to resident falls. Other allegations such as harassment and neglect were unsubstantiated.
Findings
The investigation substantiated allegations that unlicensed staff administered insulin and that the facility failed to provide adequate supervision and care for a resident with seizures and wandering behavior. Other allegations such as harassment by another resident and leaving a resident in soiled sheets were unsubstantiated.

Deficiencies (4)
CCR 87705(c)(4): The facility failed to ensure adequate direct care staff to support residents' physical and safety needs, evidenced by repeated falls and wandering of a resident with seizures.
CCR 87629(b)(1): The facility allowed an unlicensed employee to administer insulin injections, violating injection administration requirements.
CCR 87625(b)(3): The facility failed to keep incontinent residents clean and dry, as documented by repeated incontinence in clothing and odors.
CCR 87207: The facility made false claims by having a nurse sign medication administration records for insulin injections they did not administer.
Report Facts
Facility Capacity: 132 Resident Census: 70

Employees mentioned
NameTitleContext
Melissa ParksLicensing Program AnalystConducted the complaint investigation
Mark MorrisAdministratorFacility administrator interviewed during investigation
Maribeth SentySupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 67 Capacity: 132 Deficiencies: 0 Date: Sep 28, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-03-10 regarding non-adherence to Covid-19 masking, quarantining/isolation, testing protocols, and inadequate PPE provision for staff.

Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found the allegations to be unsubstantiated. The facility had adequate PPE supplies, observed Covid-positive residents quarantined appropriately, and staff were wearing PPE when entering Covid-positive apartments.

Report Facts
Facility Capacity: 132 Resident Census: 67

Employees mentioned
NameTitleContext
Melissa ParksLicensing EvaluatorConducted the complaint investigation
Mark MorrisAdministratorFacility administrator met during the investigation

Inspection Report

Complaint Investigation
Census: 67 Capacity: 132 Deficiencies: 0 Date: Sep 28, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-01-17 regarding staff behavior and resident care at the facility.

Complaint Details
The complaint was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found no evidence to substantiate the allegations of staff grabbing a resident's arm or screaming in their face. Documentation and staff interviews indicated the resident had a history of behaviors and sometimes refused care, including incontinence care.

Report Facts
Facility Capacity: 132 Resident Census: 67

Inspection Report

Complaint Investigation
Census: 69 Capacity: 132 Deficiencies: 3 Date: Jun 15, 2023

Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2022-11-22 regarding resident catheter monitoring, supervision of fall-risk residents, and timely medical attention.

Complaint Details
The complaint investigation was substantiated for failure to properly monitor a resident's catheter and supervise a fall-risk resident, resulting in a fractured shoulder and laceration. A $500 civil penalty for serious bodily injury will be issued. One allegation regarding lack of skilled professional assistance with catheter care was found unfounded.
Findings
The investigation substantiated that facility staff failed to properly monitor a resident's catheter and did not adequately supervise a resident who sustained multiple falls, resulting in serious injury. One allegation regarding lack of skilled professional assistance with catheter care was found unfounded.

Deficiencies (3)
CCR 87466 requires residents to be regularly observed for physical changes and for such changes to be documented and reported to the resident's physician and responsible person. This was not met as R1's POA and doctor were not notified of catheter drainage issues, posing immediate risk.
HSC 1569.312(e) requires monitoring residents under facility supervision to ensure health and safety. This was not met as R1 sustained multiple falls, posing direct risk to resident safety.
CCR 87623 requires written documentation of staff training by a skilled professional on catheter care procedures. This was not met due to lack of documented staff training related to R1's catheter care, posing an indirect threat to resident safety.
Report Facts
Civil penalty amount: 500 Home health nurse visits: 9

Employees mentioned
NameTitleContext
Melissa ParksLicensing Program AnalystConducted the complaint investigation
Mark MorrisAdministratorFacility administrator met with evaluator and agreed to submit memos for corrections

Inspection Report

Complaint Investigation
Census: 69 Capacity: 132 Deficiencies: 4 Date: Jun 15, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-01-11 regarding multiple allegations including physical abuse, failure to safeguard resident belongings, failure to report incidents, and medication administration issues.

Complaint Details
The complaint investigation was substantiated for allegations of physical abuse, failure to safeguard belongings, failure to report, and medication errors. One allegation regarding failure to seek timely medical attention was unsubstantiated.
Findings
The investigation substantiated allegations of physical abuse, failure to safeguard resident belongings, failure to report incidents, and failure to administer medication as prescribed. One allegation regarding failure to seek timely medical attention was found unsubstantiated.

Deficiencies (4)
HSC 87468.1(a)(3) Personal Rights of Residents were violated as staff forcefully grabbed a resident's hands during care, posing an immediate risk to health and safety.
CCR 87465(a)(5) The licensee failed to assist residents with self-administered medications as prescribed, posing a direct risk to resident health and safety.
CCR 87211(a)(1)(D) Reporting requirements were not met as no SOC341 or LIC624 reports were submitted to the Ombudsman or Licensing, posing a potential risk to resident health and safety.
CCR 87218(a)(2) The facility failed to safeguard resident property, as a resident's glasses and dentures were lost and not reimbursed, posing a potential risk to resident health and safety.
Report Facts
Facility Capacity: 132 Census: 69 Medication non-administration dates: 15 Replacement denture estimate: 8000

Inspection Report

Complaint Investigation
Census: 71 Capacity: 132 Deficiencies: 0 Date: Jun 6, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-02-14 alleging that facility staff failed to monitor a resident's water and food intake resulting in hospitalization.

Complaint Details
The complaint alleged failure by facility staff to monitor a resident's water and food intake resulting in hospitalization. The allegation was found to be unsubstantiated after review of resident records and interviews with staff.
Findings
The investigation found that the resident had the capacity to feed themselves and was independent for meals without requiring reminders. The allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation occurred.

Report Facts
Capacity: 132 Census: 71

Employees mentioned
NameTitleContext
Mark MorrisAdministratorMet with Licensing Program Analyst during investigation
Melissa ParksLicensing Program AnalystConducted the complaint investigation

Inspection Report

Complaint Investigation
Census: 73 Capacity: 132 Deficiencies: 0 Date: Jun 1, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-03-15 alleging that staff do not distribute residents' medications as prescribed.

Complaint Details
The complaint alleged that staff do not distribute residents' medications as prescribed. The allegation was found to be unsubstantiated due to insufficient evidence and lack of specific incidents, residents, dates, or staff involved.
Findings
The Licensing Program Analyst interviewed staff and residents and found that medication administration procedures allowed an hour before and after the prescribed time. Due to lack of specific incidents or evidence, the allegation was found to be unsubstantiated.

Report Facts
Capacity: 132 Census: 73

Employees mentioned
NameTitleContext
Melissa ParksLicensing Program AnalystConducted the complaint investigation
Mark MorrisAdministratorFacility administrator met during investigation

Inspection Report

Complaint Investigation
Capacity: 132 Deficiencies: 3 Date: May 11, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-04-06 regarding allegations of resident weight loss and medication mismanagement.

Complaint Details
The complaint investigation was substantiated for allegations that the resident lost severe weight while in care and that staff mismanaged the resident's medication. Other allegations of neglect, failure to assist, failure to meet nutritional needs, and isolation were unsubstantiated.
Findings
The investigation substantiated that the resident experienced severe weight loss without proper communication to the physician and that PRN medication was administered without physician contact as required. Other allegations related to neglect and nutritional needs were unsubstantiated.

Deficiencies (3)
CCR 87466: The licensee failed to ensure residents are regularly observed for changes such as unusual weight loss and that such changes are documented and communicated to the physician. No communication occurred regarding the resident's weight loss, posing a direct threat to health and safety.
CCR 87465(d)(1): Facility staff did not contact the resident's physician prior to each dose of PRN medication when the resident could not determine the need for medication. No documentation showed physician contact before administering PRN medication, posing a direct threat to health and safety.
CCR 87465(e)(2): The PRN medication order lacked exact dosage instructions, stating a range of ½ tablet (25mg) to 1 tablet (50mg) for insomnia, which poses a direct threat to resident health and safety.
Report Facts
Facility Capacity: 132 PRN Medication Administration: 9

Employees mentioned
NameTitleContext
Melissa ParksLicensing Program AnalystConducted the complaint investigation and authored the report
Mark MorrisAdministratorFacility administrator met with the evaluator during the investigation

Inspection Report

Complaint Investigation
Capacity: 132 Deficiencies: 0 Date: May 11, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-01-19 alleging inappropriate restraint, improper assessment before residency, and denial of access to a resident's personal belongings.

Complaint Details
The complaint alleged that a resident was being inappropriately restrained, was not properly assessed before residing in the facility, and that staff were not providing access to the resident's personal belongings. The investigation concluded these allegations were unfounded.
Findings
The investigation found the allegations to be unfounded. Staff interviews and record reviews showed that the resident was properly assessed, was not inappropriately restrained, and that staff followed proper procedures regarding access to personal belongings and power of attorney paperwork.

Inspection Report

Annual Inspection
Census: 69 Capacity: 132 Deficiencies: 0 Date: Jan 17, 2023

Visit Reason
The visit was conducted as a required unannounced annual inspection to evaluate the facility's compliance with regulations.

Findings
The facility was found to be in substantial compliance with no deficiencies cited. No immediate health, safety, or personal rights violations were observed during the inspection.

Inspection Report

Complaint Investigation
Census: 73 Capacity: 132 Deficiencies: 0 Date: Oct 25, 2022

Visit Reason
The visit was an unannounced complaint investigation triggered by multiple allegations including neglect, insufficient staffing, medication mismanagement, and other resident care concerns.

Complaint Details
The complaint investigation was conducted regarding allegations of neglect, lack of care, insufficient staffing, medication mismanagement, and other issues. The allegations were found to be unfounded based on documentation review and staff interviews.
Findings
The investigation found the facility staffing sufficient and no evidence of neglect or medication errors. The resident's room was kept clean, temperature was comfortable, hydration was adequate, and allegations were determined to be unfounded.

Report Facts
Capacity: 132 Census: 73

Employees mentioned
NameTitleContext
Melissa ParksLicensing EvaluatorConducted the complaint investigation
Jo Ann FranklinAdministratorFacility administrator named in the report
Mark MorrisMet with during the investigation
Maribeth SentySupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 75 Capacity: 132 Deficiencies: 0 Date: Aug 23, 2022

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-03-07 alleging unlicensed personnel were administering blood sugar checks and G-Tube feedings.

Complaint Details
The complaint alleged that blood sugar checks and G-Tube feedings were being administered by someone who was not a skilled professional. After investigation, including interviews with staff and review of physician orders and exception requests, the allegations were found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegations to be unsubstantiated. Interviews and documentation showed that only licensed nurses assisted with blood sugar checks and G-Tube feedings, and the facility maintained appropriate oversight and training for staff.

Report Facts
Facility Capacity: 132 Resident Census: 75 Residents on Insulin: 4 Residents needing blood sugar assistance: 1 Facility Staff Interviewed: 6

Employees mentioned
NameTitleContext
Sarena KeosavangLicensing Program AnalystConducted the complaint investigation
Mark MorrisExecutive DirectorMet with Licensing Program Analyst during investigation
Denise LandgrafMemory Care DirectorProvided interview statements regarding blood sugar checks and nursing staff
Anthony PerezSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 69 Capacity: 132 Deficiencies: 0 Date: Jun 6, 2022

Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were locking residents' doors from the outside.

Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The allegation was found to be unsubstantiated based on the investigation and interview with the Executive Director. No deficiencies were cited.

Employees mentioned
NameTitleContext
Jacob WilliamsLicensing Program AnalystConducted the complaint investigation.
Mark MorrisExecutive DirectorInterviewed during the complaint investigation.

Inspection Report

Annual Inspection
Census: 60 Capacity: 132 Deficiencies: 0 Date: Mar 24, 2022

Visit Reason
The inspection was conducted as the required annual unannounced inspection to evaluate the health and safety compliance of the facility.

Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during this inspection.

Employees mentioned
NameTitleContext
Mark MorrisMaintenance DirectorMet with during the inspection and toured the facility together.
Jacob WilliamsLicensing Program AnalystConducted the annual inspection.

Inspection Report

Complaint Investigation
Census: 67 Capacity: 132 Deficiencies: 1 Date: Mar 9, 2022

Visit Reason
The visit was an unannounced complaint investigation conducted due to an allegation that the facility was not following proper COVID-19 mask guidance.

Complaint Details
The complaint was substantiated based on the preponderance of evidence. The allegation that the facility was not following proper COVID-19 mask guidance was confirmed during the investigation.
Findings
The complaint was substantiated as staff were observed not wearing masks inside the facility, violating COVID-19 mask guidance. One deficiency was cited related to residents' personal rights and health safety.

Deficiencies (1)
CCR 80072(a)(2) Personal Rights of Residents: Facility staff were not wearing masks inside the facility, posing a potential health and safety risk to residents.
Report Facts
Deficiencies cited: 1 Census: 67 Total Capacity: 132

Employees mentioned
NameTitleContext
Jo Ann FranklinExecutive DirectorMet with Licensing Program Analyst during complaint investigation and exit interview
Sarena KeosavangLicensing Program AnalystConducted the complaint investigation
Anthony PerezSupervisorSupervisor overseeing the investigation

Inspection Report

Census: 60 Capacity: 132 Deficiencies: 0 Date: Oct 22, 2021

Visit Reason
The visit was a case management visit to verify that a former employee (S1) was no longer employed or associated with the facility.

Findings
No deficiencies were observed during the visit. The administrator confirmed the termination of the employee on 10/19/2020 and that the employee has not been in the facility since.

Employees mentioned
NameTitleContext
Melissa LusbyLicensing EvaluatorConducted the case management visit.
Zahra SamirAdministratorConfirmed termination of employee S1.

Inspection Report

Annual Inspection
Census: 62 Capacity: 132 Deficiencies: 0 Date: Sep 8, 2021

Visit Reason
The visit was conducted as a required unannounced annual inspection to evaluate the health and safety compliance of the facility.

Findings
The facility was found to be in substantial compliance with no deficiencies cited. No immediate health, safety, or personal rights violations were observed during the tour.

Employees mentioned
NameTitleContext
Zahra SamirAdministratorFacility administrator involved in infection control domain completion.
Stephanie BroadnaxResident Services Director, LVNMet with licensing evaluator and toured facility.
Shannon HargisMemory Care DirectorToured facility with licensing evaluator.

Inspection Report

Complaint Investigation
Census: 58 Capacity: 132 Deficiencies: 0 Date: Jun 16, 2021

Visit Reason
The investigation was conducted in response to complaints alleging that the facility was not responding to pendants in a timely manner and that a resident was not being provided with water leading to UTI/hospitalization.

Complaint Details
The complaint investigation was unannounced and conducted by Evaluator Melissa Lusby on June 16, 2021. The allegations were found to be unsubstantiated and unfounded after review of medical records, nursing notes, service plans, and interviews. The department confirmed that staff communication ensured residents' needs were met.
Findings
The investigation found the allegations to be unsubstantiated and unfounded. The department concluded there was insufficient evidence to prove the alleged violations occurred.

Report Facts
Facility Capacity: 132 Resident Census: 58

Inspection Report

Complaint Investigation
Census: 59 Capacity: 132 Deficiencies: 1 Date: Apr 16, 2021

Visit Reason
The inspection was an unannounced complaint investigation conducted due to multiple allegations received on 07/03/2020 regarding medication storage, staff training, response to residents' needs, overmedication, and safety concerns due to repeated falls.

Complaint Details
The complaint investigation was substantiated for improper medication storage but unsubstantiated or unfounded for allegations related to staff training, response to residents' needs, overmedication, and safety from falls.
Findings
The investigation substantiated the allegation that the facility was not properly storing medication, citing deficiencies related to medication being left in residents' rooms. Other allegations regarding staff training, response to residents' needs, overmedication, and safety due to falls were found to be unsubstantiated or unfounded with no deficiencies cited.

Deficiencies (1)
CCR 87465(h)(2) requires centrally stored medicines to be kept in a safe and locked place accessible only to responsible employees. This requirement was not met as medication was left in a resident's room, posing an immediate threat to resident health and safety.
Report Facts
Facility Capacity: 132 Resident Census: 59 Estimated Days of Completion: 0

Employees mentioned
NameTitleContext
Melissa LusbyLicensing Program AnalystConducted the complaint investigation
Anthony PerezLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation
Zahra SamirAssistant Executive DirectorFacility representative involved in investigation and exit interviews
Sabrina BoyleAdministratorFacility administrator involved in investigation and exit interviews

Inspection Report

Complaint Investigation
Census: 59 Capacity: 132 Deficiencies: 0 Date: Apr 16, 2021

Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2020-08-05 regarding untimely food provision and improper medication administration, as well as unsanitary conditions and lack of activities for residents.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not providing food timely, not administering medication as prescribed, unsanitary resident apartment, and lack of activities. The findings concluded no violations were proven.
Findings
The investigation found all allegations to be unsubstantiated or unfounded with no deficiencies cited. The evidence did not support that violations occurred related to food provision, medication administration, sanitation, or activities.

Report Facts
Facility Capacity: 132 Resident Census: 59

Employees mentioned
NameTitleContext
Melissa LusbyLicensing Program AnalystConducted the complaint investigation and contacted the facility
Zahra SamirAssistant Executive DirectorFacility representative met during the investigation

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