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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312955
Report Date: 04/09/2021
Date Signed: 04/09/2021 03:44:39 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: 97DATE:
04/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Kevin LitterereTIME COMPLETED:
03:11 PM
NARRATIVE
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On 04/08/21, Licensing Program Analyst (LPA) Suong Teh and Licensing Program Analyst (LPA) Christina Valerio conducted an unannounced case management via cellphone, due to COVID-19 precautionary measures, with Administrator (ADM) Bridgette Crummie and Administrator Kevin Letterer. LPAs discussed the purpose of the call, which was to discuss evidence found during a review of facility files.

According to R1’s Appraisal- Needs and Services Plan dated 07/03/2020, a home health nurse (HHN) is to change his catheter once a month. Staff 2 (S2) admitted that no HHN came to facility in 2020 and facility on-going notes show zero documentation of an HHN coming to the facility to change R1 catheter.

During the file reviews, it was discovered resident #1 (R1) had an order for antibiotic therapy to start on 08/22/20 but was not dispense until 08/25/20.

Deficiencies cited under Title 22, Division 6. See LIC 809D. Appeal Rights Given.

Exit interview was conducted with Administrator where LPAs reviewed report. An Electronic copy of the report, and appeal rights with a ‘read-delivery receipt’ was emailed to the facility to obtain a signature from the Administrator and emailed back to LPA Suong.Teh@dss.ca.gov to be filed

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
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: 04/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2021
Section Cited

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87505 Documentation and Support:
Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457, Pre-admission Appraisal, and 87463, Reappraisals. If supporting documentation from a physician is required, this input shall also be obtained and may be the same
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 assessment as required in Section 87458, Medical Assessment.
This requirement is not met as evidenced by: Based on interviews, and review R1’s file, it was discovered that R1’s Appraisal- Needs and Services Plan was not accurately reported. This poses a potential health risk to the residents in care.
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Type A
04/10/2021
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 interviews, and review of facility files, the facility administrator admitted that R1 did not received his antibiotic for three days. 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: 04/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2021
LIC809 (FAS) - (06/04)
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