342700835-7-8-2021-27-AS-TSTH-C4QQK2-20210708121338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 07/08/2021
Date Signed: 07/08/2021 12:13:43 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 LIVING		FACILITY NUMBER:	342700835
ADMINISTRATOR:	LITTERER, KEVIN		FACILITY TYPE:	740
ADDRESS:	6254 66TH AVENUE		TELEPHONE:	(408) 741-2950
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	121	CENSUS: 102	DATE:	07/08/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:32 AM
MET WITH:	Kevin Litterer		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Announced Prelicensing visit was made out to this facility on 07/08/2021 by LPA Teh. This LPA was met by the facility designated Administrator Kevin Litterer and Revenue Circle Manager Bridgette Crummie. who were briefly interviewed. This Applicant is seeking licensure for a 121 bed RCFE of which cleared for (121) Ambulatory,( 0) Non Ambulatory and (0) Bedridden at any given time. However, Kevin stated that the fire clearance will need to correct as (121) Non Ambulatory. Facility will submit a new LIC200. This information will be given to the Central Applications Bureau for follow-up. LPA observed no postage for COVID-19 procedures for washing hands, wearing mask, and COVID questionaire for symptoms. Current census is 102 residents. Tour of the facility was conducted. Kitchen area was toured. Cabinets and drawers were observed to be in good repair and contained all required dishes, cook ware, and flatware sufficient to meet the needs of the residents at this time. Cabinets storing knives and cleaning agents were observed to be locked and made inaccessible to the residents at this time. It was observed that there was a gate that latched separating the kitchen area from the common dining area. Food storage units were reviewed and observed to be set at the proper temperatures for the refrigerator and freezer components. Common areas were toured such as the living room, dining room, and all other areas intended for resident use. Furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time. A tour of the resident bedrooms was conducted. it was observed that resident bedrooms were furnished and maintained to meet the needs of the residents at this time. Resident restrooms were toured. Grab bars and non skid mats/surfaces were observed to be present and in good repair at this time. The hot water was measured to make sure that it was within the allowed range of 106 degrees.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 342700835
	VISIT DATE: 07/08/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Linen closet was observed to contain all of the necessary components sufficient to meet the needs of the residents at this time.

Total 14 fre extinguishers throughout the building were observed to have been annually serviced by the local fire authority on 07/11/2020 and in compliance at this time.

It was observed that there were no deficiencies observed or cited during today's Prelicensing visit and this facility has been found to be in compliance at this time.

Component III was conducted and completed at this time.

Exit Interview

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2