342700835-1-13-2022-27-AS-CVAO-CAMVVD-20220113154609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 01/13/2022
Date Signed: 01/13/2022 03:46:56 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:	01/13/2022
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Caleb Summerhayes		TIME COMPLETED:	02:20 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	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 Healthcare-Associated Infections (HAI) Program summary and recommendations from the HAI visit conducted on 01/05/2022. As of today, there are 17 positive residents and 14 positive staff. A red zone is being utilized for positive residents. The facility created a COVID tracker to reflect staff vaccination status and/or exempt status and booster status. Administrator completed and submitted to the Regional Office on 1/07/2022. Administrator stated the facility has implemented all HAI recommendations apart from 2 that are in progress (i.e. HEPA filters and FIT testing for staff). The facility was recommended to follow CAL-OSHA requirements for N95 Fit testing for all staff which will be set in place by 1/19/22, to ensure alcohol based hand rub dispensers are available on mobile medication cart for use when dispensing medications, to encourage compliance with social distancing in breakroom and smoking areas, to remind and redirect resident not wearing a mask when outside their room, to chort residents in dining room, to ensure staff are well when they report for work, to remove negative residents out of positive rooms, to ensure surfaces remain wet for 20 minutes when using ph7Q disinfectant, to ensure PPE cart is fully stocked with all supplies to care for resident... Continues on LIC 809-C...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

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: 01/13/2022

NARRATIVE

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, to have trash cans that are hands free located in resident’s room, to cohort staff to care for positive residents, to consider portable air cleaners with HEPA filters in positive rooms and communal spaces to improve air quality, and to instruct staff to bundle care tasks to conserve PPE and limit number of entries into isolation rooms.

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 the hard copy and send to the Regional Office via fax (916) 263-4744 by COB 01/13/2022.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

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