312700555-1-28-2025-59-AS-TORZ-DE9RD4-20250226115519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700555
Report Date: 01/28/2025
Date Signed: 01/28/2025 10:29:52 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2024 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20241004154635

FACILITY NAME:	SUMMERSET LINCOLN ASSISTED LIVING		FACILITY NUMBER:	312700555
ADMINISTRATOR:	MEGAN GALLAGHER		FACILITY TYPE:	740
ADDRESS:	550 2ND ST		TELEPHONE:	(916) 644-3151
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	162	CENSUS: 95	DATE:	01/28/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Megan Gallagher		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

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

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 59-AS-20241004154635

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET LINCOLN ASSISTED LIVING	FACILITY NUMBER: 312700555
	VISIT DATE: 01/28/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2