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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312955
Report Date: 03/04/2021
Date Signed: 03/04/2021 01:44:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CITY CREEK ASSISTED LIVINGFACILITY NUMBER:
340312955
ADMINISTRATOR:CRUMMIE, BRIDGETTEFACILITY TYPE:
740
ADDRESS:6254 66TH AVE.TELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121; 121CENSUS: 94DATE:
03/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Kevin LettererTIME COMPLETED:
01:15 PM
NARRATIVE
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On 03/04/2021 at 12:38pm Licensing Program Analyst (LPA) Suong Teh conducted a via telephone Case Management call regarding an AWOL incident report that was received on 03/03/2021. A telephone call was made in compliance with the department's procedure regarding COVID-19. LPA spoke to Kevin Letterer and explained reason for the call.

The incident report stated on 02/25/2021 ~@2:00pm facility Medtech was leaving the facility noticed resident #1 (R1) was on the street and alert the facility staff. The report stated that R1 was fighting the staff when they tried to redirect R1 back to the facility. 9-1-1 was contacted to a acute hospital for evaluation.

On 03/04/2021, LPA interviewed staff #1(S1) and learned that R1 had tried to leave the facility last summer but it was redirected by staff.

The facility administrator Kevin Letterer confirmed that there was no LIC625 Appraisal/Needs Services Plan in R1's file.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. A copy of this report has been emailed to the facility and the administrator was advised that a signed copy of the report shall be submitted to CCLD within 10 days of receipt of this report. Exit interview conducted.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CITY CREEK ASSISTED LIVING
FACILITY NUMBER: 340312955
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2021
Section Cited

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87465(a)Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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This requirement is not met as evidenced by: Based on LPA interviews were conducted, and resident records were reviewed, the licensee did not develope resident#1's appraisal/needs and services plan. This poses a potential health risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2021
LIC809 (FAS) - (06/04)
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