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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340312955
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:24:10 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2021 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20210812093559
FACILITY NAME:CITY CREEK ASSISTED LIVINGFACILITY NUMBER:
340312955
ADMINISTRATOR:RFACILITY TYPE:
740
ADDRESS:6254 66TH AVE.TELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:0CENSUS: 102DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cora CiobanuTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident not given medications as prescribed.
Facility staff did not seek medical attention in a timely manner
Staff did not provide care resulting in resident sustaining pressure sore/wounds
Neglect of resident leading to dehydration and hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/3/21 at 9:15am to deliver the findings from the investigation of the above mentioned allegations. LPA met with Cora Ciobanu, LVN, Caleb Summerhays and stated the purpose of the visit.

Community Care Licensing received a complaint on 8/12/21 alleging the above-mentioned allegations.
Regarding allegation, “Resident not given medications as prescribed”, the investigation revealed that resident #1 (R1) was not given medications as prescribed as it was documented on the Medication Administration Records (MAR) dated July and August 2021 which also indicated that on multiple dates R1 did not receive various medications. Interviews revealed that R1’s Primary Care Physician (PCP) was aware of the refusals and that R1 was under the care of specialists for medical care. Staff stated that the medications were offered at varying times but R1 kept refusing. None of the documentation indicate that the facility was seeking assistance from the PCP to re-evaluate the medications or R1 for medication management to remain in compliance. As a result, R1 missed multiple medications on multiple dates.
Substantiated
Estimated Days of Completion: 60
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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 5
Control Number 27-AS-20210812093559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/03/2021
NARRATIVE
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Regarding allegation, “Facility staff did not seek medical attention in a timely manner”, the investigation revealed documentation that R1 was refusing food, water, care, and medications sporadically for several months and was sent to the hospital on 8/10/21. Although the PCP was made aware R1 was refusing medication and seeing specialists there was no documentation that the PCP was made aware of the refusal of food, water, and care as well. During interviews staff stated that R1 often refused to go to the hospital and should have been sent to the hospital sooner for changes in condition. The Medical Intensive Care Unit (MICU) Physician concur that R1 should have been brought to the hospital sooner due to an altered level of consciousness.

Regarding allegation, “Staff did not provide care resulting in resident sustaining pressure injuries”, the investigation revealed that during R1’s hospitalization a wound care nurse noted 3 unstageable pressure injuries on R1’s sacrum measuring .5cm each and 1 stage 2 pressure injuries on the coccyx measuring 1.5 x .5cm.
Staff reported that the pressure injuries(s) were not observed until the day R1 was sent to the hospital on 8/10/21. While R1’s care plan dated June 2021, indicated some assistance with personal care and showering as needed, staff interviews were conflicting regarding the care assistance R1 actually needed and received. R1 was not receiving services from Home Health or Hospice for wound care and the PCP records do not indicate any wound care plans, and R1's skin integrity had not been checked.

Regarding allegation, “Neglect of resident leading to dehydration and hospitalization”, the investigation revealed R1 was admitted to the MICU for severe dehydration. The MICU Physician described R1 as pale, very skinny, and malnourished. The MICU Physician emphasized that it takes longer than a day for a person to be so dehydrated that they have to be seen in the MICU. R1’s Care Plan indicated that staff must monitor fluid intake, however, there were no facility records to indicate staff were providing hydration or documenting fluid intake.

Based on observation, interviews, and documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following civil penalty in the amount of $500.00 is assessed today and deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; additional civil penalties may be assessed. The facility staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2021 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20210812093559

FACILITY NAME:CITY CREEK ASSISTED LIVINGFACILITY NUMBER:
340312955
ADMINISTRATOR:RFACILITY TYPE:
740
ADDRESS:6254 66TH AVE.TELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:0CENSUS: 102DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cora CiobanuTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff neglected resident leading to significant weight loss
INVESTIGATION FINDINGS:
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Regarding allegation, “Facility staff neglected resident leading to significant weight loss”, the investigation revealed that R1's facility records indicate R1 weighed 125lbs in April 2021, and 119lbs on July 2021. By hospitalization on August 10, 2021, R1 weighed 106lbs and 2 days later gained weighing in at 116lbs. A file review revealed that R1 was not on a special diet and staff were to offer food that can be tolerated. Staff stated that R1 often refused food. The statements of staff did not corroborate that they noticed if R1 was having significant weight loss.
Based on interviews, documentation, and medical records, there appears to be no negligence on behalf of the staff. The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found 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.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion: 60
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20210812093559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2021
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
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Administrator shall provide confirmation of understanding of this regulation. POC will be provided by POC due date


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This regulation was not met as evidence by: The licensee did not ensure that persons having prohibited health conditions were not retained in the facility. Based on documentation, R1 had 3 unstageable pressure injuries. This poses an immediate risk to residents in care.
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You are hereby assessed a Civil penalty in the amount of of $500.
Type A
12/04/2021
Section Cited
CCR
87464d
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Basic Services. A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...
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A plan shall be submitted to CCL regarding in-service training to staff about adherence to care plans by POC due date.

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This regulation was not met as evidence by: The licensee did not ensure that the facility met the resident's needs. Based on information provided through documentation and interviews, staff were not following the residents plan of care.
This poses an immediate risk to 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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210812093559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2021
Section Cited
CCR
87465(d)(1-3)
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Incidental Medical and Dental Care
If the resident is unable to determine his/her own need... facility staff shall contact the resident's physician...and receive direction...
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Licensee shall submit plan on when an In-service to medication staff will be completed regarding protocols and procedures.
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This requirement is not met as evidenced by: Facility did not ensure prescribed medications were administered timely. Based on interviews that confirmed, the Licensee did not administer medications as prescribed. This possess an immediate health and safety risk to residents in care.
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Type A
12/04/2021
Section Cited
CCR
87466
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Observation of a Resident 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.
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Licensee shall develop a protocol and update their plan of operation on how to ensure all residents are monitored timely to receive the proper care and supervision as needed.

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This requirement is not met as evidenced by: Based on documentation review, the licensee did not bring to the PCP's or the responsible party's attention that R1 was refusing food, water, care, and medications sporadically for several months This violation poses an immediate health, and safety risk to 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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5