Summerset Lincoln Assisted Living

Allegation investigated: Staff are not allowing residents to leave their rooms Staff do not ensure residents are provided a comfortable environment

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday August 11, 2026, to conduct a complaint investigation. LPA met with Resident Services Director Shalon and explained purpose of visit. LPA learned the following: On Thursday July 30, 2026, one resident was sent to the hospital with symptoms of vomiting and diarrhea. Resident was diagnosed with norovirus the following day. The facility reported this to the Department and cross reported it to Placer County Public Health on Friday July 31, 2026. Per the guidance of Public Health, the following precautions were implemented to minimize the spread of the disease: deep cleaning of common areas, meals delivered to resident rooms on disposable dishware and utensils, and group activities were paused. Residents were encouraged to stay in their rooms but not required to do so. Visitors were notified of the illness and encouraged to pause visitation but were never restricted from visiting. No medical appointments were cancelled. Residents who needed assistance with ambulating were offered 1:1 assistance from staff to walk around the building or the Unfounded courtyard. Per Public Health’s guidance, the facility could not resume normal activities until all facility residents and staff were 24-hour symptom free. The facility resumed normal operations and activities on Monday August 10, 2026. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 59-AS-20260804154416

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 13, 2026 to conduct a case management visit on an incident which was reported to the Department on March 30, 2026. LPA met with Resident Services Director Shalon and explained the purpose of the visit. LPA and Shalon discussed R1's fall which occurred on 3/26/2026. R1 was found on the floor by NOC shift staff. R1 denied falling or hitting their head. The following day, R1 spoke with Shalon and stated that they did fall but did not tell staff. R1 was experiencing pain in their left hip and could not stand. AMR was called for R1. R1 was diagnosed with a left hip fracture. LPA reviewed' R1's physicians report and care plan. R1 was independent in ambulation, toileting, dressing, and grooming. Facility staff were conducting status checks 4x per shift and assisting with medication management. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday January 7, 2026, to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (10) and staff (8) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA, Administrator Sabrina, and Resident Services Director Shalon Morris toured the facility together to ensure the health and safety of residents in care. The areas toured included the following areas: resident apartments, resident bathrooms, common areas, kitchen, laundry rooms, medication rooms and courtyard. Facility had current inspection tags on fire extinguishers. Facility was current on fire drills. Water temperatures were within the required range. Facility had fully stocked first aid kits. All required postings were observed. Facility was clean and well organized. In the areas toured, there were no health or safety violations observed. LPA obtained a current LIC500 and liability insurance. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jan 7, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday December 17, 2025 to follow-up on a death report that was received by the Department on December 16, 2025. LPA met with Shalon, Resident Services Director. R1 had a unwitnessed fall on 12/9/2025. R1's POA found R1 around 8:30am, sitting on the floor with their arm between the bed and night stand. R1 complained of pain. Staff called 911 and resident was sent out for evaluation. At the hospital, R1 was diagnosed with sepsis of unknown origin and organ failure and passed on 12/12/2025. R1 moved into the facility 9/29/2025. Upon move-in, staff assisted R1 with medication management, status checks, and psychosocial prompting. On 12/5/2025, Shalon reassessed resident and their current care plan included medication management and minimal status checks. R1 was independent with bathing, dressing, grooming, eating, and toileting. R1 did not have a diagnosis of cognitive impairment. LPA obtained a copy of R1's physicians report and assessments (2). LPA requested a copy of R1's death report, when available. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday October 14, 2025, to conduct a case management on an incident report received by the Department on Monday October 13, 2025. LPA met with Sabrina Boyle and Shalon Morris, Resident Services Director. LPA learned that on 10/11/2025, R1 pressed their wall cord around 4:10am. Staff arrived and found R1 on the floor. R1 stated they fell. R1 was independent of ADLS except for medication management. LPA obtained a copy of R1's assessment, care plan and physicians report. R1 was recently reassessed on 9/16/2025. R1 is currently at the hospital and will then be transferred to a SNF for rehab. Shalon will reassess R1 before they return to the facility. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.the state’s words, verbatim · CDSS document, Oct 14, 2025

Allegation investigated: Staff are mishandling resident medications Resident are not treated with dignity and respect

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 07/29/2025 to complete and deliver findings to a complaint received on 01/27/2024. LPA met with Executive Director, Sabrina Boyle and explained the purpose of the visit. Throughout the course of the investigation, the department conducted interviews and record reviews. Please continue to LIC9099C.. Unfounded Allegation: Staff are mishandling resident medications During the course of the investigation, LPA interviewed Executive Director, three (3) caregivers/med-techs, and one (1) resident. LPA reviewed Medication Administrator Record (MAR) for R1 and found no discrepancies in the files. Through interviews with S2, S3, and S4 it was determined that several med-techs would review the MARs throughout the week. LPA did an audit comparing physicians’ orders and the present medications. LPA observed all prescribed and scheduled medications were available to R1. Based on facility tour, interviews and observation, the department found this allegation is to be UNFOUNDED. Allegation: Resident are not treated with dignity and respect During facility visits LPA observed staff were attentive to resident’s needs and providing them privacy while taking care of them and during resident’s personal time with families and visitors. During residents’ interviews, R1 stated that facility staff are meeting their care needs and did not express any concerns with privacy, respect or dignity. R1 indicated that staff were treating all residents with dignity and respect and did not express any issues. Based on facility tour, interviews and observation, the department found this allegation is to be UNFOUNDED. Based on information obtained, LPA finds the above allegation to be UNFOUNDED- A finding that the complaint is Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 59-AS-20250127111610

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Insufficient staffing led to severe falls Call buttons are not answered timely

On 1/28/25, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Megan Gallagher. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unsubstantiated Insufficient staffing led to severe falls: Unsubstantiated On 12/02/2024, R1 sustained an unwitnessed fall in their room. Interviews indicated, R1 pushed their pendant for help. Interviews indicated staff responded timely to R1’s pendant call. Staff assisted R1 up. R1 stated they felt a little soreness in their knees and felt a some of pain. On 12/02/2024, S1 was taken to the emergency room (ER). Medical records revealed that R1 was discharged from the hospital with a diagnosis of a fracture of sacrum without disruption of pelvic ring. Based on records review, R1 sustained (4) unwitnessed falls in their apartment. Staff would respond timely when R1 would push their pendant. Although R1 sustained a fall which caused them injury, the Department has determined that R1’s falls were not a result of staff’s lack of care or supervision. Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Call buttons are not answered timely: Unsubstantiated The department conducted interviews and reviewed records to investigate the allegation. During residents’ interview, residents stated that staff respond to their call buttons in timely manner however sometimes there is a delay in response due to staff assisting other resident’s needs. During call button log review, the department did not observe any long or extended wait times from staff to respond to resident's call button. As a result of this investigation, LPA finds allegation to be UNSUBSTANTIATED - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 59-AS-20241004154635

Type of visit: Required - 1 Year

On 01/21/25 Licensing Program Analysts (LPAs) Graham Gunby and Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection. LPAs met with Executive Director (ED), Megan Gallagher, and explained the purpose of the visit. LPAs and ED conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: (10) resident rooms, laundry room, kitchen, dining room, theater, sports lounge, mail area, medication room and common areas. LPAs observed residents in common areas participating in activities and in the dining room having lunch. The residence was found to be clean, safe, sanitary and in good condition. LPA observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. LPA conducted a file review of ten (10) resident files and ten (10) staff files. Resident and staff files had all the required documents present in files. No deficiencies cited. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 21, 2025

Allegation investigated: Staff do not ensure that resident's medication is administered as prescribed Staff are falsifying resident’s medication administration record

On 10/31/2024 , Licensing Program Analysts (LPA) Graham Gunby and Cheyenne Ratajczak arrived and met with Administrator to deliver investigation findings. Based upon interview with the administrator and review of client roster, The department has determined the client does not reside in this facility and the complaint was made against the wrong facility. Therefore, the complaint is unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was given. Unfoundedthe state’s words, verbatim · CDSS document, Oct 31, 2024 · control 59-AS-20241021142405

Allegation investigated: Staff mismanaged resident’s medication

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Monday July 29, 2024 to complete and deliver findings to a complaint received on 7/19/2024. LPA met with Administrator Rouzbeh and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed R1’s medication list, incident report, and hourly wellness checks. The result of the investigation is as follows: LPA learned that the facility has two med techs to pass out AM shift medications. One med tech is assigned to the first floor while the other is assigned to the second floor. The third floor is divided between the two med techs. S1 provided S2 with a list of their assigned residents on the third floor. On July 19, 2024, S1 gave R1 their morning medications. Approximately 90 minutes later, S2 gave R1 a second dose of the same seven morning medications. Once the facility realized the medication error, the following people were contacted: poison control, R1’s primary physician, R1’s power of attorney, and management. Per the guidance of poison control, R1 was to be monitored hourly and did not need medical intervention. Substantiated Based on the information detailed above, LPA finds the allegation to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 29, 2024 · control 59-AS-20240719114058

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jul 30, 2024

Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: based on interview stated that R1 received duplicate medications. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2024

Plan of correction: The facility terminated S2. Facility agrees to send LPA date/time for next staff training regarding medication errors by end of day 7/30/2024.

Allegation investigated: Facility staff did not dispense medications as prescribed Facility staff did not assist resident with dressing

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday June 27, 2024, to complete and deliver findings for a complaint received on 5/8/2024. LPA met with Administrator Rouzbeh and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed facility staff including the Administrator, Resident Services Director, Wellness Director, med techs, and caregivers. LPA reviewed R1’s file including PRN authorization, controlled drug records, communication with primary physician, resident assessment, physician reports, resident notes, physician orders, and PRN MAR. LPA interviewed staff who revealed that R1 is able to communicate when they are in pain. R1 had PRN orders for Tramadol 50mg for moderate oto severe pain and acetaminophen 325 mg as needed for pain. No staff interviews revealed that R1 was ever refused pain medication. LPA did review a faxed message to R1’s primary physician, requesting a refill order for Tramadol. R1 has a primary diagnosis of CHF exacerbation and mild cognitive impairment. R1, at times, has refused to get out of bed. No staff Unfounded interviews acknowledged that R1 was refused assistance with dressing or care . Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 27, 2024 · control 59-AS-20240508150927

Allegation investigated: Staff did not follow their emergency disaster plan

LPA Parks arrived on Monday March 11, 2024, to conclude a complaint investigation regarding the above allegation. LPA met with Administrator Rouzbeh and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, facility staff and R1. LPA reviewed the generator’s test runs and the facility’s Emergency and Disaster Plan. LPA learned that there was a city-wide power outage from Sunday February 11th until the evening of Monday February 12th. While the facility does have a portable generator (which they share with their next-door sister facility Summerset Lincoln Assisted Living and Memory Care), the generator was not functioning properly. Upon the power outage, the generator was not putting out voltage. The facility rented a portable generator to use. The generator service company determined there was a fuse that was burned out on the generator. The issue was immediately fixed and the company the yearly maintenance service. The facility immediately began to follow their Emergency and Disaster Plan by doing the following: renting a generator which supplied power to the common areas, contacting DME company to Unsubstantiated provide oxygen tanks for residents, resident frequent checks by staff, and utilizing the emergency evacuation chair if residents needed to access a different floor. LPA determined that the facility did follow their emergency plan in place when there was a power outage. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Mar 11, 2024 · control 59-AS-20240212120457

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday January 4, 2024 to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (10) and staff (8) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA along with Jeff and future Administrator Rouzeh Moradhasel toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, resident bathrooms, common areas, kitchen, laundry rooms, medication rooms, and balconies. LPA observed the facility's emergency food, water storage and PPE. In the areas toured, there were no health or safety violations observed. LPA requested an updated LIC500 and LIC610E. Additionally, LPA requested a copy of the current liability insurance. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Jan 4, 2024

Allegation investigated: Staff mismanaged resident’s medication

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday September 28, 2023, to complete and deliver findings to a complaint received on 9/15/2023. LPA met with Administrator Jeff and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and Wellness Director. LPA interviewed R1 and R2 regarding the allegations. LPA reviewed R1’s file at the facility including physicians report, progress notes, and MARs. The result of the investigation is as follows: On 8/13/2023, R1 was running low on two medications (Atrovastatin and Amloidipine). Staff reordered the medication, however, not within the timeframe for resident to not miss any doses. Additionally, one medication needed the primary physician’s signature for the prescription to be renewed. Based on interviews, R1 was out of one medication as of 8/15 or 8/16 (unsure due to inconsistent documentation on MARs). Based on R1’s MARs, one medication was out for 3 days and the other for 5 days. Substantiated Based on the information detailed above, LPA finds the allegation to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. occurrence as it is for temporary amount of time. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 59-AS-20230911134523

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Sep 29, 2023

87465(a)(5) Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: based on interview and MAR document review, resident was not given medication as prescribed. This poses a direct risk to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Administrator to submit plan of med tech training regarding medications.