340312955-6-17-2021-27-AS-SRIN-C4C4RR-20210625192023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340312955
Report Date: 06/17/2021
Date Signed: 06/17/2021 01:37:07 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
09/17/2020 and conducted by Evaluator Tuyet-Suong Teh

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200917140822

FACILITY NAME:	CITY CREEK ASSISTED LIVING		FACILITY NUMBER:	340312955
ADMINISTRATOR:	CRUMMIE, BRIDGETTE		FACILITY TYPE:	740
ADDRESS:	6254 66TH AVE.		TELEPHONE:	(916) 393-2324
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	121; 121	CENSUS: 100	DATE:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Kevin Litterer		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident not given medications as prescribed.
Facility staff not following care plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Suong Teh made subsequent complaint investigation on 06/16/21 to deliver the findings. LPA spoke to the facility administrator Kevin Litterer and explained the purpose of the visit.

On 09/18/20 The Department interviewed the Reporting Party (RP) Resident #1 (R1) was admitted to the emergency room on 09/11/21 and did not return to City Creek Assisted Living. The Department do not have a current address where R1 have moved to.

On 10/23/20 @2:49 pm LPA spoke to the facility Revenue Control Manager (RCM) and requested resident #1 (R1)’s records. On 05/26/21@10:32 am LPA interviewed Revenue Control Manager and requested R1’s missing nurses documents. During the interview, RCM confirmed that R1 choose which medication that he wanted to take. RCM confirmed that R1 had antibiotic medication but refused to take it.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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-20200917140822

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: 06/17/2021

NARRATIVE

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LPA discovered on 08/25/20 nurse's notes stated that R1 refused to take the antibiotic. The facility faxed a notification to R1’s doctor to confirm a discontinue order on 08/25/21.

On 05/25/21 @11:06 am LPA Teh interviewed Staff #1 (S1). S1 stated that R1 did not have any issue taking his medications. S1 stated that R1 never refused his medications. NOTE: LPA observed a note from S1 stated that R1 refused one medication dated on September 03, 2020.

On 06/09/21 and 06/10/21 LPA attempted to contact Staff #2 (S2) and on both days were not receive a call back.

On 06/09/21 @1:31pm LPA Teh called Staff #3 (S3). S3 stated to work at Saint Francis Assisted Living before it became City Creek Assisted Living. S3 stated that she left City Creek Assisted Living around the end of September of 2020. S3 stated that she was assigned as the NOC shift Med Tech. S3 stated that her job required her to order medications, log in all new orders, log when resident refused to take the medication and contacted their primary physician; S3 stated to remember R1. S3 stated that R1 was a difficult resident when it comes to taking his antibiotic medication. According to S3, R1 would refuse to take his antibiotic medication and even contacted his doctor to discontinue it. According to S3, R1 is on top of his narcotic medication. S3 stated an earlier incident occurred when R1 was just moved to City Creek Assisted Living, R1 requested for more narcotic even he had exceeded the 3x daily. S3 stated that R1 complained to have severe pain and requested to for 9-1-1. According to S3, R1 would state severe pain and somehow got more narcotic at the hospital and was sent back to City Creek Assisted Living in a lethargic condition.

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

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