Summerset Lincoln Assisted Living and Memory Care

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday September 10, 2026 to conduct an unannounced case management visit. LPA met with Administer Megan and explained the purpose of the visit. LPA and Administrator discussed the death report of R1, who passed away not on hospice. LPA learned the following: R1 had a diagnosis of heart failure, hypertension, generalized weakness, and mild cognitive impairment. Staff assisted them with bathing, dressing, transfers, and medication. R1 was able to press their pendant when they needed assistance. On 9/1/2026, staff were conducting their NOC shift routine status checks. They observed R1 was unresponsive in their bed. 911 was called. R1 was transported to the hospital where they were pronounced deceased. LPA requested a copy of R1's death certificate, when available. LPA obtained a copy of R1's POLST, physicians report and care plan. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 10, 2026

Allegation investigated: Staff did not dispense medications as prescribed Staff did not seek medical attention for resident in a timely manner unqualified staff performed a restricted health procedure

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday July 23, 2026, unannounced to conduct a complaint visit regarding the above allegations. LPA met with Sabrina Boyle and Maybeth Chace and explained the purpose of the visit. LPA interviewed staff regarding the allegations. LPA learned the following: On July 7, 2026, staff who is a new med tech (S1), was administering medications. S1 provided R1 with the medication Glipizide 20 mg which belonged to another resident. S1 then informed the nurse on duty (N1) of the error. S1 and N1 then contacted the facility Administrator for guidance. Per the facility Administrator, they were to monitor the resident and conduct hourly blood sugar checks. N1 conducted blood sugar checks until the end of their shift at 8pm. Then, S1, who is not a skilled professional, was instructed to conduct the blood sugar checks. S1 and other med techs at the facility were unable to obtain a blood sugar reading. According to staff interviews, S1 became weak and did not respond to their name when checked around 9:20pm. The Substantiated NOC shift began at 10pm, staff observed R1 to be sweating and unresponsive. S2, who works as a NOC shift caregiver at the facility, is also a certified phlebotomist, obtained a blood sugar of 34. 911 was then called around 10:40pm for the resident to be sent to the hospital for evaluation. Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegations are substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency cited on 9099-D. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 23, 2026 · control 59-AS-20260708103639

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 24, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. . . . (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by R1 being provided and consuming the medication for another resident. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Facility to submit plan regarding retraining med techs.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jul 24, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. . . .(5) Facility staff, except those authorized by law, shall not administer injections . . .this requirement was not met as evidenced by med techs performing finger sticks for blood sugar checks. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Facility to submit inservice training to LPA regarding protocol and procedures for blood sugar checks.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jul 24, 2026

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis . . this requirement was not met as evidenced by staff not calling 911 once they began to have a serious change in condition. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2026

Plan of correction: Facility to submit plan to retrain all staff regarding policy on calling 911 in the event of an emergency.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 20, 2026 to conduct a case management visit on an incident which was reported to the Department on April 1, 2026. LPA met with interim Executive Director Desiree and explained the purpose of the visit. On March 31, 2026 around dinner time, R1 had a choking incident. Staff observed resident was choking, slumped over and turning blue. Staff performed multiple attempts of the Heimlich Maneuver and was able to clear the blockage. Food was scooped out of R1's mouth and their color returned to baseline. Facility nurse assessed resident and was laid on their side. AMR was called and transported the resident to Sutter ER for evaluation. There was no diagnosis given on hospital discharge paperwork with instructions to follow up with primary physician. At the time of the choking incident, R1 had an order for thickened liquids and a regular diet. One 4/4/2026, the facility received a call from the hospital stating that R1 would return with orders for thickened liquids and puree diet. R1 was placed on hospice on 4/10/2026 once resident returned to the facility. LPA obtained a copy of R1's original and updated physicians report, hospital discharge paperwork, and resident notes. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 20, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday May 20, 2026 to conduct a case management visit on an incident which was reported to the Department on May 2, 2026. LPA met with interim Executive Director Desiree and explained the purpose of the visit. LPA and Desiree discussed R1's incident on 4/24/2026. R1 had a fall on 4/17/2026. This fall occurred because another resident opened a door, which caused R1 to fall. 911 was called and R1 was sent to Sutter ER for evaluation. ER discharged R1 with a diagnosis of injury of right shoulder, initial encounter. Xrays were conducted and no signs of broken bones. On 4/23/2026, R1's primary physician arrived at facility and assessed R1. This primary physician said that R1 did not need to wear a shoulder sling and advised the facility to monitor the resident and give Tylenol as needed. On 4/24/2026, staff observed R1's right hand was swollen with complaints of severe pain. R1 was transported back to Sutter ER where they were diagnosed with a closed displaced fracture of the humeral neck at the right shoulder. R1 returned to the facility with instructions to make a follow-up appointment with an orthopedic surgeon. On 4/27/2026, Desiree called to follow-up with the orthopedics office to try and schedule an appointment. Family then decided to place R1 on hospice services. R1 was admitted to hospice services on 4/29/2026. LPA obtained a copy of R1's physicians report, care plan, hospital discharge paperwork. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 20, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Wednesday January 21, 2026, to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (8) and staff (8) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA and Resident Services Director Desiree toured the facility together to ensure the health and safety of residents in care. The areas toured included the following areas in memory care and assisted living: resident apartments (11), resident bathrooms, common areas, kitchen, 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 kit. 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 current LIC500, liability insurance, LIC308, and LIC610E. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Jan 21, 2026

Allegation investigated: Staff are not responding to resident's call button in a timely manner Staff are not providing a comfortable environment for resident Staff are not treating resident with dignity Staff are retaliating against resident for filing a complaint

On 12/08/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Megan Gallagher. LPA conducted room inspections, records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. The following are the findings regarding allegations listed: Staff are not responding to resident's call button in a timely manner- LPAs reviewed call button records and interviews. There are extensive call response records for staff response to R1's calls for assistance. Additionally it is reported that R1 has, at times, also used their cell phone to call directly to the facility phone for assistance. While records show some call times to exceed 15 minutes, there is no specific call response time dictated in Title 22 regulations; rather, regulations require that the care assistance needs are met with sufficient and competent staffing. This requirement was met. Unsubstantiated Review of records and interviews also found that R1 requires stand-by assist for transfers and ADLs. Interviews also found that R1 is not always compliant to ask for and wait for assistance. Some of the reported times where R1 needed to wait for staff assist from the toilet were times where R1 did not notify staff before self ambulating to the toilet so staff longer responses could be attributed to delays due to care for others. Staff are not providing a comfortable environment for resident- Interviews and inspections found R1's room to have the required furniture and fixtures. Additionally, staff provide regular house keeping and pet care for R1's dog. R1's room was observed to be clean and odor- free. Part of what was reported as discomforts were noises such as an adjacent door alarm, other residents' alarms needed for their care or behavioral expressions of others. As R1 resides in a memory care facility in which noises of others or others' equipment, those noises, while unfortunate, do not constitute an uncomfortable environment under Title 22 requirements. Staff are not treating resident with dignity- Observations and interviews did not find sufficient evidence that facility staff have not treated R1 with dignity and respect. Records found that R1 has care needs in the high care level. Additionally, R1 received approximately 14- 20 call response by staff in the Sept call logs reviewed. Interviews found that staff interact with R1 respectfully during those interactions. In interactions with management, R1's, care needs and expectations have been regularly discussed. Staff are retaliating against resident for filing a complaint- LPAs based on interviews did not find evidence that staff have retaliated toward R1. R1 receives the care identified by respectful staff. There has been no disruption to the care of R1 or R1's dog. R1 is not being evicted. Any known disagreements between management, R1 or R1's family , regarding care, costs or expectations, have not impacted R1's care. As a result of this investigation, LPA finds allegation to be (US)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 with administrator.the state’s words, verbatim · CDSS document, Dec 8, 2025 · control 59-AS-20250930160714

Allegation investigated: Staff does not ensure residents are provided a safe environment.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegation. LPA met with Administrator Megan Gallagher during today’s investigation. LPA investigated allegation, “Staff does not ensure residents are provided a safe environment.” During investigation LPA reviewed resident documentation, toured the facility, and conducted interviews. Relevant party indicated that R1 has behaviors that are upsetting to other residents and causing an unsafe environment. LPA reviewed R1’s LIC602 dated 07/30/25, in which it stated R1 has a diagnosis of dementia with psychotic disturbance. LIC602 states R1 can have inappropriate behaviors, wandering behaviors, and sundowning behaviors. LPA interviewed administrator in which she stated, R1 began to have behaviors but R1 received medical care and R1’s behaviors are now well managed. Currently R1 is receiving hospice care. LPA was able to confirm this with facility and medical documents. Continuation on 9099-C. Unfounded LPA was able to conclude that R1 did have behaviors however facility reported all behaviors to responsible party and doctor and was able to receive medical care for the behaviors. Due to the information gathered LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of report given.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 59-AS-20250725095321

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

On March 6, 2025, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Director, Megan Gallagher to deliver complaint findings for the above allegation. LPA was accompanied by an observer from CCLD’s policy division. The department reviewed resident records, facility records and conducted extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was reported that on October 19, 2024 R1 did not receive as needed pain medications as prescribed and requested. Physician’s orders for R1’s pain medication states as needed every 4 hours for pain. Statements alleged that at approximately 4:30 PM, On October 19, 2024, R1 requested pain medication. Med tech, S1, sought clarity of timing between R1’s medications before dispensing. Later in the evening, R1 again requested pain medication from S1. R1 alleged that medication was not dispensed at S1 left for water and did not return. Unsubstantiated Medication Administration records (MAR) and Controlled Drug records (CDR) for R1 were reviewed and found the following: The MAR had recorded controlled drug PRN dispensed to R1, on October 19th at 5:25 PM. This was not a significant variation of the time periods for this medication for this resident. While CCR regulations do require documentation of PRN medications administration, and inconsistencies were found between the MAR and CDR, additional evidence was not found to support that the inconsistencies were intentional or fraudulent. As a result of this investigation, LPA finds allegation to be (US)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 with administrator.the state’s words, verbatim · CDSS document, Mar 6, 2025 · control 59-AS-20241030160128

Allegation investigated: Staff do not ensure that resident's pendant calls are answered in a timely manner. Staff did not ensure that resident's toileting needs are met.

On March 6, 2025,, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met withDirector, MeganGallagher. LPA was accompanied by an observer from CCLD’s policy division. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. Regarding-Staff do not ensure that resident's pendant calls are answered in a timely manner. Records reviews, call records and staff interaction records did not support the allegation. Regarding- Staff did not ensure that resident's toileting needs are met. R1 records show R1 independently toilets and requires intermittent assistance. Supporting evidence was not found to support that R1's toileting needs are not met As a result of this investigation, LPA finds allegation to be (US)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 with administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 6, 2025 · control 59-AS-20241031111456

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Graham Gunby arrived on Thursday February 13, 2025 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 (10) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included common areas, medication rooms, kitchen, and dining rooms. LPA observed the facility's emergency food, water storage and PPE. All water temperatures were within the required range. First aid kit is fully stocked. In the areas toured, there were no health or safety violations observed. LPA received a copy of the facility's liability insurance. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Executive Director.the state’s words, verbatim · CDSS document, Feb 13, 2025

Allegation investigated: Staff did not provide medical attention to resident in a timely manner. Facility has insufficient staff to provide care to residents. Staff not meeting resident’s dietary needs.

On February 12, 2025, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Administrator. The department conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy for the following allegations: Staff did not provide medical attention to resident in a timely manner- The two incident for R1 that were mentioned on the complaint found that there was not sufficent evidence that the allegation could be substantiated. The incidents in July and August of 2024 where R1 experienced changes in their condition were documented and staff interviewed to show that staff responded as directed by R1's physician and according to R1's plan of care. Following each incident of a previously unidentified care need, R1's physician was contacted and the plan of care was updated as needed. Facility has insufficient staff to provide care to residents- Staff schedules for August and September 2024 were reviewed as well as staff and residnt interviews conducted. Additional evidence was not found to support that there were insuffient staff to meet the needs of resident identified care needs. Unsubstantiated Staff not meeting resident’s dietary needs- the facility is licensed as a non-medical/ non- secure facility. Records and observations of R1 found R1 to be able to freely ambulate in the facility. Furthermore, R1, due to memory impairment was unable to retain physician's recommendation to limit fluids and types of drinks. If R1 was observed to exceed fluids guidance, the facility staff notified the physician of R1's observed intake. When R1 was observed to be seeking excessive fluids, staff intervened to offer information to R1 and attempt to redirect. If R1 continued to insist, staff did not violate R1's personal rights. As a result of this investigation, LPA finds allegation to be (US)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 with administrator.the state’s words, verbatim · CDSS document, Feb 12, 2025 · control 59-AS-20240904164258

Allegation investigated: Staff failed to seek medical attention for a UTI and dehydration.

Licensing Program Analysts (LPAs) Graham Gunby and Cheyenne Ratajczak arrived unannounced on 12/18/2024 to complete and deliver findings to a complaint received on 1/17/2024. LPAs met with Executive Director, Megan Gallagher and explained the purpose of the visit. Throughout the course of the investigation, the department conducted interviews and record reviews. Please continue to LIC9099C.. Substantiated Allegation: Staff failed to seek medical attention for a UTI and dehydration. Substantiated Staff reported R1 had changes in condition beginning in November 2023. They observed R1’s urine was dark in color and had an odor consistent with a urinary tract infection (UTI). Medical records show R1 was seen at the emergency room on 11/17/2023 for a chief complaint of lethargy. However, medical records show not show a urinalysis test was conducted or that they were ever treated for a UTI. Medical records from this visit show R1 was assessed for behavioral issues and their medications were adjusted. On 12/18/2023, staff began noticing a decline in R1’s condition which included changes in weakness and mobility. Staff contacted R1’s family recommending R1 be places on hospice care. The file review records indicate R1’s primary care physician was not contacted regarding R1’s signs of weakness until 12/24/2023. On 12/24/2023, a fax correspondence was sent to R1’s primary care physician indicating R1 was lethargic, sedentary, and no longer able to feed themselves. The physician did not acknowledge receipt of the correspondence. Multiple staff considered R1’s changes in condition to be drastic and warranted her being sent out to the hospital on 12/24/2023. Staff reported R1 was sent out to the hospital on 12/24/2023. However, medical records support R1 was not sent out to the hospital until 12/25/2023 at approximately 1600 hours. As a result of this investigation, LPA finds the allegation to be Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted. A copy of this report was left with the facility. Allegation: Neglect resulted in resident's death. Unsubstantiated On 12/25/2023, R1 was admitted to the hospital after exhibiting signs of shortness of breath and being unresponsive. R1 was discharged from the hospital on 12/28/2023 and returned to Summerset with a diagnosis of severe sepsis with acute organ dysfunction and urinary tract infraction (UTI). R1 was placed on hospice care on 12/28/2023 and passed away on 1/9/2024. R1’s death certificate lists cause of death as cardiac arrest and pneumonia. Other significant conditions contributing to their death were pulmonary embolism and severe dementia. Based on the information obtained, there is insufficient evidence that facility staff neglected R1 resulting in R1’s death. Allegation: Resident developed a UTI and became dehydrated due to inadequate care by staff. Unsubstantiated R1’s medical records documented that whenR1 arrived at the hospital on 12/25/2023, they tested positive for a urinary tract infection (UTI) and had signs of dehydration. Staff reported R1 consistently received assistance with toileting and brief changes in a timely manner. Staff also reported R1 consumed and appropriate amount of liquids and did not show any signs of dehydration. It is unclear if R1 had a history of sustaining frequent UTIs and required special measures. Interviews with residents documented staff meet resident’s needs. Based on the information provided, although R1 was diagnosed with a UTI and dehydration, there is insufficient information that staff provided inadequate care. Allegation: Staff did not ensure that resident's room was sanitary. Unsubstantiated Staff interviews revealed that R1 would often have a bowel movement not in the bathroom. Interviews detailed how R1 would the try to hide the BM. Notes detail R1 having a bowel movement on the wall and then screaming at staff when being redirected. Staff stated that R1’s room was generally clean and well kept. Staff interviews also acknowledged that R1 would frequently take all the clothes out of their closet and drawers, causing staff to have to frequently have organize and put the room back together. Based on the information provided, there is insufficient information that staff did not ensure resident’s room was kept sanitary. Allegations: Staff do not provide services to resident as promised. Staff did not ensure that resident's hygiene needs were met while in care. Unsubstantiated LPA interviewed staff regarding the allegations. Interviews stated that R1 was, at time, combative and resistant to care. Staff stated that they would ask R1 multiple times to assist with showering and would try a change of face. LPA reviewed resident notes which detail R1’s combative behavior to care including: ‘attacking’ hospice shower aid and becoming combative with staff. LPA reviewed doctor orders which show an increase in R1’s medications to assist with behaviors. Based on the information provided, staff were documenting when staff were unable to meet R1’s needs. Allegation: Staff handled resident in a rough manner, causing injury to resident. Unsubstantiated LPA reviewed resident notes which detail ongoing combative and aggressive behavior by R1. R1 had a history of being aggressive with staff and other residents. Additionally, notes detail R1 ‘not letting go’ of another resident, grabbing resident’s hair from the back of their head, and screaming. LPA did not identify any incident which R1 had a skin tear due to staff. LPA did not review any documentation regarding R1 having a skin tear or doctor notification of a skin tear. Additionally, facility did not submit an incident report or SOC341 to the department regarding a skin tear R1 sustained caused by staff. Staff interviews indicated that staff did not observe a skin tear on R1. Based on this information, these allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. Exit interview conducted. A copy of this report was left with the facility.the state’s words, verbatim · CDSS document, Dec 18, 2024 · control 59-AS-20240117154538

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 19, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:Based on interviews conducted and records reviewed, facility staff observed R1’s health declining on 12/18/2024. Although facility staff reached out to R1’s responsible party, facility staff did not reach out to R1’s primary physician until 12/24/2024 resulting in a delay in R1 obtaining proper medical care.the state’s words, verbatim · CDSS document, Dec 18, 2024

Plan of correction: Licensee will complete a statement of understanding for regulation 87466. Licensee will also show proof for a planned trainning with staff. Licensee will email to LPA by POC due date, 12/19/2024.

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Resident wandered away from the facility due to lack of care and supervision Staff billed resident for services not rendered

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday September 26, 2024, to complete and deliver findings to a complaint received on 7/25/2024. LPA met with Administrator Megan and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed R1’s physicians report, incident report, police report, resident assessment, monthly billing, email communication, and nursing notes. The result of the investigation is as follows: Allegation: Resident wandered away from the facility due to lack of care and supervision. At approximately 9pm on July 8, 2024, LPA learned that the delayed egress alarm on a second-floor door went off. Staff checked the alarm but did not check the hallway nor did they check to ensure all residents were accounted for. When the morning shift began on July 9, 2024, they noticed that R1 was not in the facility. Per the police report, the facility called in a missing person’s report at 7:36am. R1 was located 8:12am at a local business. Substantiated An immediate civil penalty of $500 was issued due to lack of supervision which led to R1's eloping and wandering away from the facility. Allegation: Staff billed resident for services not rendered. LPA reviewed R1’s assessment dated 6/11/2024 which shows that R1 needed the following care: status checks (16 per shift), psychosocial (behavioral interventions), dressing, laundry, medication assistance, and special care (exit seeking). This combination of care put R1 at a level 5 which was billed at $3,000 per month. On the night that R1 eloped from the facility, staff were assigned to complete 16 status checks per shift in addition to supervising R1 for exit seeking. Therefore, R1 was being billed for supervision that was not being provided at the time of the elopement. Based on the information detailed above, LPA finds the allegations 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. teleconference and frequent emails. Allegation: Staff do not answer facility telephone Title 22 regulations and California Health and Safety Code does not specify that staff are required to answer the facility phone. There is a regulation that states the resident has the right to reasonable access to telephones to both make and receive confidential calls. The regulation, however, does not define what reasonable is. The facility does have a receptionist between the hours of 8am until 8pm. A review of the resident's care plan does not have a time frame for staff to expect a phone call for the resident in question which is not required but could have helped to ensure the resident would get the phone call. Based on information obtained, LPA finds the allegations 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. A copy of this report was left with the facility.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 59-AS-20240725172932

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Sep 27, 2024

87705(c) (4) Care of Persons with Dementia. (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by R1 eloping from facility without staff knowledge. This posed a direct threat to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Facility previously submitted staffing training for regarding elopment. This citation is cleared upon the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Oct 3, 2024

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: facility billing for care services which were not rendered between the days of 7/8/2024 and 7/9/2024 including frequent checks (16 per shift) and redirecting regarding exit seeking behavior. This posed an indirect threat to the health and safety of resident in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Facility agrees to issue a refund for care and supervision for 7/8 and 7/9/2024.

Allegation investigated: Unqualified staff is providing care and supervision to diabetic residents Unqualified staff is administering medication Staff mishandled the residents medical records Staff did not meet the residents medical needs while in care Staff mishandled the residents medications Staff did not properly discard expired medication Staff are not being properly trained

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Thursday September 26, 2024 to complete and deliver findings to a complaint received on 1/11/2024. LPA met with Administrator Megan and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and staff. LPA reviewed staffing schedules, staff files, and CSMDR. The result of the investigation is as follows: Allegations: Unqualified staff is providing care and supervision to diabetic residents, Unqualified staff is administering medication, Staff mishandled the residents medical records LPA reviewed text messages between S1 and various facility employees. These text messages reveal that there were shifts when a nurse was not scheduled. However, LPA previously cited the facility on 10/11/2023 regarding unqualified staff performing insulin administration. LPA did not obtain or review any new information that the facility continued this practice after the citation was issued. According to current staff interviews, there is always a nurse in the building to perform the assigned tasks of a skilled Unsubstantiated professional. No interviews revealed that an employee, who is not a nurse, is currently performing insulin administration. Allegation: Staff are not being properly trained LPA reviewed 8 staff files. These files were a mixture of care staff including nurse, med tech, and caregivers. LPA observed all the required documents in staff files. Additionally, LPA observed the required annual and continuous training for staff. No files revealed that staff were working independently prior to receiving the required training. Facility also provided in-service training which are conducted as needed. Allegations: Staff did not meet the resident’s medical needs while in care, Staff mishandled the resident’s medications. LPA interviewed staff who denied having any knowledge of a resident receiving a duplicate dose of medications. Staff stated that they follow doctor’s orders in regards to medications. LPA reviewed incident reports submitted to Licensing and did not identify any which discuss a resident’s medication being mismanaged. Staff did not properly discard expired medication. LPA interviewed staff who all described the proper process to destroy medications. Staff acknowledged that non-narcotics are destroyed with two employees. Narcotics are destroyed with the Administrator and one other employee. LPA reviewed centrally stored and destruction logs which were filled out appropriately. Based on information obtained, LPA finds the allegations 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. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 59-AS-20240111104820

Allegation investigated: Staff did not provide a comfortable and safe environment for residents Staff did not make sure backup generator was in working condition

LPA Parks arrived on Monday March 11, 2024, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Mark and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and facility staff. LPA reviewed the generator’s test run log 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), the generator was not functioning properly. Upon the power outage, the generator was not putting out voltage. The generator service company determined there was a fuse that had burned out on the generator. The issue was immediately fixed and the company conducted the yearly 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 and residents Unsubstantiated rooms (not nurse call system), contacting DME company to provide oxygen tanks for residents, resident frequent checks by staff, providing extra flashlights, blankets and pillows, 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 allegations 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-20240206164023

Type of visit: Office

An informal conference was conducted on Wednesday February 14, 2024, in the Sacramento North Regional Office. The purpose of this informal conference meeting is to discuss the high volume of complaints/ inability to remain in substantial compliance with the regulations/or specific incidents that has occurred in the last 12 months. Present in the meeting is Licensing Program Manager (LPM) Maribeth Senty, Licensing Program Analyst (LPA) Melissa Parks, Owner Rick Beasley, Regional Manager Sabrina Boyle and Administrator Mark Morris. The informal conference process was explained during this meeting. The facility has been cited 13 times in the last year. The facility was cited under the following regulations: Care of persons with Dementia, not having a skilled professional administer injections, observation of resident, monitoring the activities of residents, personal rights, medication mismanagement, not following PRN directives, and insufficient staffing. The facility was cited for 9 Type A citations, and 4 Type B citations. The licensee was told that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference, which could lead to a referral to the Department's legal division for possible revocation of license. Issues discussed during the meeting were: · Current open complaints (3) · Adequate staffing · Nursing Schedule · PRN medication · Medication Administration The facility has stated they will do the following to achieve continued and substantial compliance: Reassessing residents after falls, updating care plans, care conference with POAs if resident requires higher level of care or 1:1 supervision Staffing based on acuity, reassessments every 3-6 months or as needed Nursing sign-in book, utilizing on-call nurses if needed Reviewing PRN authorization forms for all residents Reviewing MARs to ensure they match doctors orders No deficiencies were cited during today’s meeting. An exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 14, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday February 6, 2024, to conduct a case management visit to obtain additional information on an incident which was reported to the Department on Wednesday January 31, 2024. LPA discussed the incident with Resident Services Director Emily. LPA learned that on Saturday January 27, 2024, R1 was observed to be in distress at approximately 4:20 pm. Emily observed resident attempting to clear their throat. A short time later, Emily began the Heimlich Maneuver until first responders arrived at the facility. R1 was pronounced deceased at the facility at approximately 4:57pm. LPA obtained the following documents from R1's file: physicians report, preplacement appraisal, care plan, diet clarification form, identification and emergency information form, and current service plan. Per documents, R1 was independent with meals and not on a special diet. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Feb 6, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Monday January 29, 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 and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included memory care apartments, common areas, medication rooms, kitchen, and dining rooms. LPA observed the facility's emergency food, water storage and PPE. All water temperatures were within the required range. First aid kit is fully stocked. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the facility's 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 29, 2024

Allegation investigated: Staff did not meet resident's hygiene needs. Unqualified staff administered insulin shots to residents. Staff falsified residents' medication records. Resident sustained an unwitnessed fall resulting in a fracture.

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday October 10, 2023, to complete and deliver findings to a complaint received on 4/6/2023. LPA met with Administrator Mark and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, current and previous staff. LPA interviewed R1’s POA regarding the allegations. LPA reviewed R1’s file at the facility including physicians report, nursing notes, MARs, hospital discharge paperwork, physician’s orders, and employee notes regarding R1’s POA behavior to staff. The result of the investigation is as follows: Per staff interviews, S1 worked as the resident services director. At this time, the facility scheduled nurses for 12-hour shifts. Per interviews, there were no nurses scheduled for 7 days per week. According to the allegation, S1 would conduct blood sugar checks and give R2 their insulin. S2, who is a registered nurse, would then sign the MAR. According to State records, S1 obtained their nursing license on 7/14/2022. Substantiated Previous staff interviews acknowledge witnessing S1 provide insulin injections prior to obtaining their license. Interviews from previous and current staff acknowledged that R1 needed assistance with bathing, dressing, grooming, and incontinence care. Interviews stated that R1’s was incontinent of bladder and bowel. Staff stated that, for most of R1’s stay at the facility, R1’s POA refused to provide proper incontinence products for R1. Therefore, when R1 would become incontinent, this required a change of clothing. Additionally, staff stated that it was difficult for R1 to comply with incontinence care. Nursing notes also detail R1’s refusal for showers. Interviews and nursing notes detail repeated times where R1 was observed walking without their walker. Nursing notes also detail staff attempts to have R1 use their walker. Nursing notes also detailed R1 would refuse to use their glasses or leave them in other resident apartments. R1’s physicians report indicated that they had motor impairment/paralysis and needed to use a walker to prevent falls. Additionally, R1 had a history of seizures which led to additional falls. Therefore, due to R1’s history of seizures and falls, along with wandering behavior, the facility failed to provide proper supervision. Additionally, R1’s care plan was not updated as required based on level of care. Based on the information detailed above, LPA finds the allegations 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. LPA reviewed R1’s MARs. Additionally, based on staff interviews and documentation review, LPA learned that R1 would often refuse medication. LPA reviewed communication between the facility and R1's primary physician. Nursing notes stated that R1 would become aggressive and refuse to take their medication. LPA interviewed previous and current staff who stated that R1’s had a history of agitation and being aggressive. R1 would constantly walk the hallways of the facility. LPA reviewed R1’s nursing notes which detail, at times, R1 was exit seeking. R1 had a history of going in other resident apartments and taking their items. No staff interviews revealed that R1 was being harassed by another resident. R1 had several roommates while living at the facility. Interviews acknowledged that, due to cognitive impairment of the residents, R1 and their roommate would create messes in the room. Staff stated that they tried to keep resident items organized and belongings separated. Staff interviews stated that throughout R1’s stay at the facility, there were times when the facility was short of staff due to call-ins. LPA was unable to obtain staffing schedules due to the amount of time that had passed and management turnover. Staff interviews stated that R1 was offered hydration at meals, and in between meals. Additionally, R1 had a hydration bottle. Per staff interviews, R1 would often leave the hydration bottle while walking the hallways, pour the water out, or refuse to drink. Interviews stated that R1 was constantly walking the hallways. At times, it was difficult to get R1 to sit. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations 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, Oct 10, 2023 · control 59-AS-20230406113411

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Oct 11, 2023

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety. . . This requirement was not met as evidenced by R1 having a Dx of seizures and having repeated falls and wandering. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator to submit plan regarding 1:1 and eviction procedures for residents who require additonal care and supervision outside of normal staffing.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(b)(1) · Plan of correction due date: Oct 11, 2023

87629 Injections (b) . . . the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by allowing an employee who did not have their nursing license administer insulin injections. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator to submit nursing schedule including back-up plan if schedule nurse calls off.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 27, 2023

87625 Managed Incontinence (b) . . .the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by R1 having repeated incontinence in clothing documented by nursing notes and photographs. This poses an indirect threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator to submit proof of training regarding incontinence care and cleanliness.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Oct 27, 2023

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by S2 signing the MAR regarding R2's insulin when they were not the one to administer the injection. This poses an indirect threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator to submit proof of training for care staff regarding documentation.

Allegation investigated: Staff grabbing resident arm and screaming in resident face. Staff failed to change resident.

LPA Parks arrived on Thursday September 28, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Mark and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, previous and current facility staff. LPA reviewed R1’s file including physicians report, care plan, and progress notes. Based on interviews, no staff acknowledged having witnessed or heard about staff grabbing resident’s arm or screaming in their face. Additionally, there was no documentation of this occurring in resident’s file. Based on documentation review and staff interviews, R1 had a history of behaviors and, at times, was resistant to care. Based on staff interviews, R1 would, at times, refuse incontinence care. LPA was unable to verify R1’s shower schedule, only that they required one person assist. R1's progress notes detail R1's refusal of care, including incontinence care. Unsubstantiated Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations 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, Sep 28, 2023 · control 25-AS-20230117164126

Allegation investigated: Facility is not adhering to Covid-19 masking protocols. Facility is not adhering to Covid-19 quarantining/isolation protocols. Facility is not adhering to Covid-19 testing protocols. Facility does not provide staff with adequate PPE.

LPA Parks arrived on Thursday September 28, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator Mark and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator and facility staff. LPA reviewed the facility’s Infection Control Plan. Additionally, at the time the complaint was filed, LPA conducted a facility walk-through. The result of the investigation is as follows. Throughout the facility walk-though, LPA observed (and took photos) of PPE supply. Facility has cases of N95 masks, surgical masks, gloves, gowns, and face shields. LPA also observed cases of covid-tests. LPA observed PPE carts in the hallway of covid positive residents. LPA observed cases of individual bottles of hand sanitizer and large hand sanitizer stations (in the hallway and mounted on the wall). LPA observed covid positive residents to be quarantined in their apartments, as much as possible, in a memory care unit. LPA observed staff wearing PPE when entering covid positive apartments. Unsubstantiated LPA obtained an updated copy of the covid positive and covid negative residents. Per the facility, all residents will be retested in two days. LPA interviewed staff who stated they had access to full PPE to provide care for covid positive residents. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations 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, Sep 28, 2023 · control 59-AS-20230310160924