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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340312955
Report Date: 04/09/2021
Date Signed: 04/09/2021 03:44:01 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
09/08/2020 and conducted by Evaluator Tuyet-Suong Teh
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200908113029
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
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Kevin LittererTIME COMPLETED:
03:11 PM
ALLEGATION(S):
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Facility staff did not assist resident with catheter care.
Facility staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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On 04/09/21, Licensing Program Analyst (LPA) Suong Teh and LPA Christina Valerio contacted Administrator (ADM) Bridgette Crummie and the facility administrator Kevin Letterer to commence an unannounced Tele-visit, due to COVID-19 precautionary measures, subsequent complaint investigation. LPA Teh discussed the purpose of the call which is to deliver complaint investigation findings. LPA has determined the following as it relates to the following complaint allegations.

On 04/07/2021, LPA conducted interviews with three former facility staff: Staff 1 (S1), Staff 2 (S2), Staff 3 (S3) and Staff 4 (S4). It was learned that S4 is currently out of the country and cannot be reached. On 04/08/2021, LPA attempted to contact Staff 5 (S5) twice but it was not successful. LPA contacted S1 @10:00 AM and left a message. It was learned later that the number did not belong to S1 and the facility did not have any other number for S1.

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 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
09/08/2020 and conducted by Evaluator Tuyet-Suong Teh
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200908113029

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
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Kevin LettererTIME COMPLETED:
03:11 PM
ALLEGATION(S):
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Facility staff did not keep accurate records.
INVESTIGATION FINDINGS:
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S2 stated any time she noticed a smell or anything wrong with Resident 1 (R1), she would tell the medication technician (MT) to document it. S2 stated she told MT to document the occurrences in 2019 and 2020. S2 stated she never documented health records but told other staff members to document on-going notes.
On 04/07/2021~ at 2:27 PM LPA interviewed the facility administrator Bridgette Crummie. Bridgette stated that part of the LVN’s role was to document any unusual occurrences, health changes, or concerns for all residents. Bridgette stated anyone who observes something should be the one to document the concern/issue.

According to hospital records obtained and received, LPA reviewed files and found that the hospital spoke to the facility in September of 2020. The facility could not inform the hospital of when the last time the catheter was change and stated they had no record of it in 2020.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200908113029
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: 04/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2021
Section Cited
CCR
87506(b)(11)
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87506(b)(11) Resident Records
(b) Each resident’s record shall contain at least the following information:
(11) The documentation required by Section 87611 for residents with an allowable health condition.
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The licensee agrees to submit an In-Service Training Plan to all staff and will highlight resident care documentation by the POC date.
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This requirement is not met as evidenced by: Based on interviews, medical record review, and review of facility files, the facility was not able to retain home health to check on R1’s catheter from January 2020 to September 2020. 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: Krystall MooreTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Stephen RichardsonTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20200908113029
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: 04/09/2021
NARRATIVE
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According to the facility files provided by the facility administrator Bridgette Crummie, there were 2 pages of on-going notes documented for R1 on 2020, and none of which discuss issues with the resident’s change in catheter or smell of catheter

Based on the information obtained, as a result of this investigation, the allegation is SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview was conducted with Administrator where LPA 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

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

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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20200908113029
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: 04/09/2021
NARRATIVE
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On 04/07/21, @10:08 AM LPAs contacted S2. S2 stated that she had stopped working for facility in August 2020. Over the course of 2 years, S2 stated that anytime there were issues with Resident 1 (R1) Foley catheter, she would report to the Home Health Agency. S2 said that the bag constantly had a foul odor due to R1 daily ejaculations. S2 stated that she changed the bag, if needed. S2 stated that R1 did not have any occurrences of refusing home health to change the Foley catheter in 2019 or 2020. Staff 3 (S3) stated that she recalled R1. According to S3, R1 was alert, oriented, ambulatory, and he had a habit of inserting foreign objects into his Penis.

On 09/09/2020, LPA Teh interviewed Reporting Party (RP) at 2:20 PM. RP stated that she talked to a medication technician, who did not disclose to RP that R1 had a habit of inserting foreign objects into his Penis. RP stated she talked to another staff 5 (S5), who then disclosed R1’s habit.

S2 stated that in 2019, home health nurse (HHN) came to the facility monthly to change R1’s catheter. However, S2 stated that in 2020 it was hard to find a Home Health organization to come to the facility because R1 would make HHN uncomfortable changing the catheter due to the resident making sexual advances and talking inappropriately to the HHN. In 2020, there was one occurrence that S2 had to request a nurse from City Creek Post-Acute facility to change R1’s catheter. S2 stated that she did not documented the occurrence but said that she told the medication technician to document.

The facility administrator Bridgette Crummie confirmed between October 2019 – September 2020, there was a total of 5 emergency room visits for R1. Bridgette stated that they had to send R1 to the emergency room for his catheter needing to be changed due facility was having problem to find a Home Health Agency to come to the facility. Bridgette stated that R1 had burned bridges with HHN due to his past in appropriate behaviors towards them. According to Bridgette, each ER returned that R1’s catheter was not change.

S3 stated that in 2020 she was rarely reported to City Creek Assisted Living; but, remembered that Home Health would come monthly in 2019.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is unsubstantiated. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 5 of 5