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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340312955
Report Date: 09/21/2021
Date Signed: 09/21/2021 11:21:37 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
05/10/2021 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20210510082913
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:0CENSUS: DATE:
09/21/2021
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Kevin LittererTIME COMPLETED:
10:53 AM
ALLEGATION(S):
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Medications not being administered as prescribed
Facility staff did not assist resident with glucose testing
Resident left in soiled clothing
INVESTIGATION FINDINGS:
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On 09/21/2021 at 10:00 AM, Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Kevin Litterer and explained the purpose of the visit.
 
The investigation was conducted by LPA Suong Teh and LPA Valerio. The investigation consisted of interviews with the Reporting Party, Facility Administrator Kevin L., facility staff (S1-S6), and residents (R1-R5). Medical records and facility records were obtained and reviewed. The Department has determined the following as it relates to the allegations: Medications not being administered as prescribed, Facility staff did not assist resident with glucose testing, and Resident left in soiled clothing.


Continued on LIC 9099-C...
Page 1 of 3
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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-20210510082913
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: 09/21/2021
NARRATIVE
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...Continued from LIC 9099...

On 05/17/21, Staff 1 (S1), Staff (S2), Staff 3 (S3), Staff 4 (S4), Staff 5 (S5), and Staff 6 (S6) were interviewed by LPA Valerio and LPA Teh. According to interviews, 3 out of 6 staff confirmed that there are times where residents did not received their medications due to the medication order being on hold or the facility was waiting on the pharmacy to deliver medications. According to interviews, 3 out of 6 staff stated they ensure all residents received their medications and they could not speak on behalf of the other shifts. S6 informed LPAs that she observed resident's needing medication order refills; however, orders were not sent to the pharmacy until the facility ran out. S6 stated the pharmacy takes 3-5 days to refill prescription orders. 

According to interview with staff on 05/17/21, 4 out of 6 staff reported residents with insulin always received their dose while staff were on shift. One staff reported, there was a time where a resident was out of insulin; however, the resident was given their diabetic medication in pill form.

On 05/17/21, LPA Teh and LPA Valerio reviewed Medication Administrator Records for Resident 5 (R5). Records showed R5 received new prescription medication orders from her doctor on 05/12/21. On 05/17/21, the facility did not have the physical order and staff stated they were waiting for the mail-in order to arrive at the facility. Staff confirmed that the newly prescribed medication has not been given to R5.

On 09/02/21 and 09/03/21, LPA Valerio reviewed resident records for Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4). Upon review, LPA Valerio observed 4 out of 4 residents having a minimum of 1 missed medication dose.

On R1's Medication Administration Record (MAR), R1 did not receive a dose of Glipizide, a medication used to treat Diabetes, on 04/24/21, 04/28/21, 04/29/21, 04/30/21, 05/01/21, and 05/02/21. R1's blood glucose levels were not recorded on the MAR, although a nursing note written on 03/19/21 reads "Doctor will send [an] order for [patient] blood sugar. Supplies to Kaiser Pharmacy." R1 was sent out to the ER on 05/02/21 at 11:30AM due to being observed by staff as disoriented, confused, unable to follow any directions. Nursing Note from 05/02/21 also stated, "unable to communicate his doctor due to not having his doctor information on file."

Continued on LIC 9099 -C Page 3
Page 2 of 3
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20210510082913
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: 09/21/2021
NARRATIVE
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Continued from Page 2 of LIC 9099-C...

Based on Medical Records from Kaiser Permanente South Sacramento, R1 was admitted to the hospital for hyperglycemic hyperosmolar nonketotic coma on 05/02/21. Kaiser attempted to obtain information from the facility; however, no information was recorded nor provided to Kaiser by the facility. R1 underwent treatment at Kaiser South Sacramento until 05/24/21. 

On 05/17/21, LPAs Teh and Valerio interviewed staff. Based on interviews conducted, 2 out of 2 staff members stated staff do no leave residents in their soiled diapers. Staff 4 (S4) stated that if it is busy, or S4 is helping another resident, the next resident may have to wait up to 30 minutes for S4 to be available.

On 05/17/21, LPAs Teh and Valerio interviewed residents. R5 reported that staff are always late in changing R5's diaper. R5 reported R5 had to wait 1 hour before being change, which was not an unusual occurrence. R2 confirmed the report due to living in the same room as R5.

Based on Medical Records from Kaiser Permanente South Sacramento, R1 was admitted to the hospital for hyperglycemic hyperosmolar nonketotic coma on 05/02/21. Medical Records show that R1 was admitted into the hospital in soiled diapers. Based on facility record review, the facility did not have documentation of checking on R1 or changing R1's diaper prior to finding him disoriented, confused, and unable to follow directions at 11:30 AM. 

Based on medical record review, interview, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.  California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.

An exit interview was conducted, and a copy of the report was provided to Administrator Kevin Litterer upon conclusion of visit.



Page 3 of 3.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20210510082913
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: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2021
Section Cited
CCR
87465(a)(1)
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87465Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...
(1)The licensee shall arrange, or assist in arranging, for medical...appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee has hired a new nurse manager and will ensure to comply with title 22 regulations. Nursing manager will audit the orders and ensure they are inputted in the system on a daily basis.
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Based on record review and interviews, the licensee did not ensure R1’s glucose levels were being monitored, which poses an immediate health and safety risk to residents in care.
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Type A
09/22/2021
Section Cited
CCR
87628(b)(1)
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87628 Diabetes(b) ... the licensee shall be responsible for the following:
(1) Assisting residents with self-administered medication...
This requirement was not met as evidenced by:
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Licensee has hired a new nursing manager who is in charge of auditing the Medication Administration Record (MAR) daily. Licensee will send an e-mail by POC date stating results of MAR audit confirming all medications were given on time. Licensee will ensure nursing manager audits on a weekly basis.
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Based on record review, 4 out of 4 resident records showed that they had a minimum of 1 missed medication. The licensee did not ensure staff gave all medications to residents, which poses an immediate health, safety, and personal rights risk to 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210510082913
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: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2021
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence
b)... General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidence by:
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Licensee stated all Medication Technicians will be accountable for ensuring Resident Aides have ensured all incontinent residents are kept cleand and dry. Licensee will send an e-mail by POC date with all staff signatures acknowledging the assigned daily tasks.
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Based on interviews, 3 out of 5 persons interviewed stated residents are left in soiled clothing, which poses an immediate health and safety risk to persons 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5