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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312955
Report Date: 05/17/2021
Date Signed: 05/26/2021 01:02:39 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: 96DATE:
05/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kevin LitterereTIME COMPLETED:
03:30 PM
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On 05/26/2021 LPA Teh arrived to the facility to deliver the amended report.
On 05/17/2021 Licensing Program Analyst (LPA) Suong Teh and LPA Christina Valerio made an unannounced visit to conduct an annual inspection. LPAs met with the facility administrator Kevin Litterere (Certificate #6058781740 Expiration 06/20/21) and Bridgette Crummie Revenue Control Manager. There are currently 96 residents who reside at this facility. This facility has a hospice wavier for 3 and currently there is 1 resident on Hospice. LPA inspected the interior and the exterior of the facility including the common living spaces. Bedrooms were clean and in good repair. LPA found medications being dispensed have orders and are documented as required. Facility kitchen was found to be clean with an adequate food supply for 2-day perishable and 7-day nonperishable. Smoke alarm system was checked by State Fire Marshal on 04/21/21. Hot water temperature measures at 110 degrees F. This facility is operating within the scope of their license. LPA reviewed a resident 10 and 5 staff records. Resident files were found to be complete and current. A review of staff records indicates that all facility staff have received criminal record clearances. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies during this visit. Exit interview held, Appeal Rights discussed, Copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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