340312955-11-12-2021-27-AS-SRIN-C9KUCA-20211210142732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340312955
Report Date: 11/12/2021
Date Signed: 11/12/2021 01:03:49 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 LIVING		FACILITY NUMBER:	340312955
ADMINISTRATOR:	R		FACILITY TYPE:	740
ADDRESS:	6254 66TH AVE.		TELEPHONE:	(916) 393-2324
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	0	CENSUS: 104	DATE:	11/12/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Bridgette Crummie		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not bring changes of resident’s condition to the attention of the authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/12/21 at 8:45am to investigation the above mentioned allegation. LPA met with Bridgette Crummie and stated the purpose of the visit. LPA conducted a file review of resident #1 (R1) complete file during this visit. Based on a review of the following documents; Appraisal/Needs and Services Plan dated 6/1/21, Appraisal/Needs and Services Plan dated 6/10/21, Fax Cover sheet(s), Nurse Notes', Charting Notes', Preplacement Appraisal Information, Doctors Progress Notes, Emergency Information (LIC601) dated 11/9/2018, and Admission Agreement dated 11/9/2018. The Primary Care Physician was informed of R1s non-compliance of medications, refusal of care and food. R1 was initially on a speical diet of thin liquids prior to admittance. Once admitted in 2018 to this facility R1 was on a regular diet. LPA observed that between the dates of 6/1/21 - 8/23/21, there was one date mentioned (8/10/21) indicating R1s family was informed of residents refusal of care and medication. Upon continued review of residents file, LPA observed that on the Identification and Emergency Information (LIC601), and the Admission Agreement both dated 11/9/2018 that R1 was own responsible party.

Unfounded

Estimated Days of Completion: 120

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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

LIC9099 (FAS) - (06/04)

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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: 11/12/2021

NARRATIVE

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Therefore, allegation is deemed UNFOUNDED as R1 did not have an authorized representative.

The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNFOUNDED.

“This agency has investigated the complaint alleging, the above-mentioned allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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