342700835-1-5-2022-27-AS-CVAO-CADRQQ-20220105121354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 01/05/2022
Date Signed: 01/05/2022 12:15:01 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:	CALEB SUMMERHAYS		FACILITY TYPE:	740
ADDRESS:	6254 66TH AVENUE		TELEPHONE:	(916) 393-2324
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	121	CENSUS: 101	DATE:	01/05/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	11:23 AM

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	An Office Meeting was conducted today in the Sacramento Regional Office via Microsoft Teams. Present in the meeting is Regional Manager Krystall Moore, Licensing Program Manager Stephen Richardson, Licensing Program Analyst Victoria Brown, Licensing Program Analyst Jamie Ivey-Canady, Licensing Program Analyst Christina Valerio, and representatives of T Street LLC; Administrator Caleb Summerhayes, and Resident Care Coordinator Shavell Jeffries. The purpose of this meeting is to discuss the Provider Information Notice (PIN-21-53-ASC). Pursuant to the State Public Health Officer Order of December 22, 2021, all workers who provide services or work in ASC facilities licensed by CDSS and are not otherwise exempt are required to have the first dose of a one-dose regimen or the second dose of a two-dose regimen by November 30, 2021. Two-dose vaccines include Pfizer-BioNTech or Moderna or vaccines authorized by the World Health Organization (WHO). The one-dose vaccine is Johnson and Johnson [J&J]/Janssen. On 12/31/21, CCL received a call regarding COVID-19 positive cases. The Licensee was requested to provide Recordkeeping of Worker Vaccination and Exemption Status as stated in PIN21-32.1-ASC. There are currently 2 COVID positive residents and 4 COVID positive staff. Workers may be exempt from the vaccination requirements only upon providing the licensee a declination form, dated and signed by the individual stating either of the following: (1) The worker is declining vaccination based on Religious Beliefs, or (2) The worker is excused from receiving any COVID-19 vaccine due to Qualifying Medical Reasons. Continues on LIC 809-C... Page 1 of 2

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

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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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: 01/05/2022

NARRATIVE

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...Continued from LIC 809

In this PIN, Adult Care Facilities and Direct Care Worker Vaccine Requirement requires that workers currently eligible for boosters, who provide services or work in indoor settings as specified, be fully vaccinated and receive a booster dose for COVID-19 by no later than February 1, 2022. Workers not yet eligible for boosters must be in compliance no later than 15 days after the recommended time frame.

Administrator was reminded that unvaccinated exempt workers and workers who are fully vaccinated but have not yet received a booster must test for COVID-19 once weekly in order to enter or work in the facility. These workers must also wear a surgical mask or higher-level respirator at all times while in the facility.

Administrator to provide copies of the exemptions, vaccination status, and/ or termination of employment for all 12 non-vaccinated employees to the Regional Office by COB 01/07/2022. Administrator to provide a copy of a tracker reflecting all staff's vaccination status, booster status, and exemption status to the Regional Office by COB 01/07/2022.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with Caleb Summerhayes via Microsoft Teams and a copy of this report was provided via e-mail. Administrator to sign on the hard copy and send to LPA by COB 01/05/2022.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

LIC809 (FAS) - (06/04)

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