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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340312955
Report Date: 07/19/2021
Date Signed: 07/19/2021 10:56:39 AM



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
01/15/2021 and conducted by Evaluator Tuyet-Suong Teh
COMPLAINT CONTROL NUMBER: 27-AS-20210115163441
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: 101DATE:
07/19/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kevin LittererTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Medications not being administered as prescribed.
Staff not practicing universal precautions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Suong Teh made subsequent complaint investigation on 07/19/21 to deliver the findings. LPA spoke to the facility Social Services Director Deborah Gagle and Clinical Services Director Garrett Wiman to explain the purpose of the visit.
On 07/07/21, The Department interviewed the Reporting Party (RP).
RP stated that Resident #1 (R1) called and spoke to her almost every day. RP confirmed that R1 is still residing at City Creek Assisted Living. RP stated that she and Witness #1 (W1) brought R1’s incontinent care supplies and clothes to her in April 2021. RP stated to observe staff behind the front desk did not have face mask on. RP stated sometime in April 2021, RP brought R1’s incontinent care supplies. RP noticed that R1 had a shower blanket wrapped below her waist. RP stated that when R1 ran out of clean clothes, staff would use a shower blanket to cover R1's bottoms. RP believed that R1 was also not wearing any diaper because Suzanne told them that it ran out.
RP stated that she would bring new clothes for R1 because she told her that the facility kept misplacing her clothes. RP stated that she bought permanent markers so R1 can marked her clothes. RP confirmed that R1 does her own laundry.
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: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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-20210115163441
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: 07/19/2021
NARRATIVE
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RP stated that the facility is responsible to order R1's medications. RP stated that R1 was submitted to the hospital several times in 12/2020 and diagnosed with Cellulitis due to poor hygiene.

On 07/07/21, The Department interviewed Witness #1 (W1).

According to W1, sometime in April 2021, W1 visited R1 and noticed that her hair was not brushed and had a strong urine smell. W1 observed front desk staff did not wear their mask on their visit on April 2021 and residents were sitting in the front area and did not wear a mask.

On 06/30/21, an unannounced visit was conducted, LPA Teh and LPA Valerio observed staff at the front desk with her mask pulled down below her chin.

On 07/08/21, The Department interviewed the facility Revenue Control Manager (RCM).

RCM stated that R1 did not have any conservatorship. RCM confirmed that R1 still resides at City Creek Assisted Living.

RCM confirmed that R1 can communicate for her needs and wants. RCM stated that R1 wanted her medications dispense according to her. RCM stated, for instance, R1 has two (2) different creams and she wanted a certain cream to be applied to her on different time and not according to the doctor’s order. RCM stated sometime R1 would refuse the medications. RCM admitted Med Techs were not reporting correctly on the MAR reports, therefore, she was not able to confirm whether R1 did receive her medications. RCM stated that she has not witness nor heard of anyone including staff verbally abuse R1.

NOTE: The facility did not have an incontinent care plan nor a sign sheet to show how often R1 got changed.

On 07/07/21, The Department interviewed facility Social Service Director (SSD). SSD confirmed that R1 still resides at City Creek Assisted Living. SSD stated that R1 has two (2) sisters. SSD stated that both sisters would bring food, incontinent supplies and clothes to R1. SSD stated that when residents received clothing from family, the residents or staff will mark their initial on their clothes. SSD confirmed that R1 can mark her own clothes. SSD stated that R1 likes to do her own laundry. SSD stated that, the facility also do R1's laundry. SSD stated that R1 can communicate but sometime can be forgetful. SSD stated that R1 also likes to give her clothes away when she did not want it anymore. SSD stated that she has not witnessed nor heard of anyone including staff verbally abusive toward R1.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20210115163441
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: 07/19/2021
NARRATIVE
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On 07/08/21, The Department interviewed Staff #2 (S2). S2 stated to work at City Creek Assisted Living for nearly a year. S2 confirmed that his duties are ordering medications, communicating with doctors and nurses; noting changes of residents and dispense medication to residents. S2 confirmed that he has assisted R1. S2 stated that R1 required extra attention. According to S2, on his shift R1 has never received medications late.

NOTE: R1’s Electronic Medication Administration Records (EMAR) from 12/06/20 to 12/08/20 showed about 8 medications recorded as “waiting on pharmacy.” Interviews verified that R1 was at the facility.

On 07/08/21, The Department interviewed Resident #1 (R1). R1 stated to own a personal cell phone. R1 stated to call and talk to her sister and family good friend every day.

R1 stated that between December 2020 and December 2021, her medications were not dispensed in timely manners. R1 stated that her morning pills were dispensed at noon. R1 stated that there were times that she did not have her medicated cream for a week.

R1 confirmed that she needs care 24/7. R1 stated that she gets showered twice a week but wanted to be showered every day due to incontinent issue.

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.

An exit interview was conducted with the facility Social Service Director Deborah and a copy of this report will be provided to the facility

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20210115163441
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: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2021
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care:
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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The administrator agrees to provide all departments with training on mishandled medications by POC 7/20/2021.
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(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement was not met as evidenced based on LPA reviewed electoric medication administration records (EMAR) for resident #1 (R1) and discovered 8 medications from December 6, 2020 the MAR reported “waiting on pharmacy,” and December 8, 2020.

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Type B
07/23/2021
Section Cited
HSC
1569.695(b)
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A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement was not met as evidenced by based on 06/30/2021 visit, LPA observed a front desk staff mask was placed under her chin which poses a potential health and safety risk to resident in care.

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Licensee will complete the emergency disaster plan and email copy to LPA by POC 07/23/21.
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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: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC9099 (FAS) - (06/04)
Page: 4 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
01/15/2021 and conducted by Evaluator Tuyet-Suong Teh
COMPLAINT CONTROL NUMBER: 27-AS-20210115163441

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: 101DATE:
07/19/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kevin LittererTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident hygiene needs not being met.
Medications not being ordered.
Staff verbally abusing residents.
Resident belongings are missing with no explanations.
INVESTIGATION FINDINGS:
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The Department interviewed Reporting Party (RP), Witness #1 (W1), Revenue Control Manager (RCM), Staff #1 (S1), Staff #2 (S2) and Resident #1 (R1) and R1’s records were reviewed.
The Department discovered that R1 had a medicated cream was denied 12/09/20 by R1’s physician. The Department learned from interviews that R1 does her own laundry majority of the time and R1 verified that all of her clothes are marked her initials. R1’s personal property and valuables was reviewed.
R1 stated that several staff made a fuss to her because she needed to be changed too often. R1 stated that upset her.

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.
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: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5