342700835-1-18-2022-27-AS-KHOS-CAZKKM-20220125065834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 01/18/2022
Date Signed: 01/18/2022 11:48:58 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
10/21/2021 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211021170202

FACILITY NAME:	CITY CREEK ASSISTED LIVING		FACILITY NUMBER:	342700835
ADMINISTRATOR:	LITTERER, KEVIN		FACILITY TYPE:	740
ADDRESS:	6254 66TH AVENUE		TELEPHONE:	(916) 599-7033
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	121	CENSUS: 101	DATE:	01/18/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio was screened for COVID-19 symptoms with temperature taken prior to being allowed entry. The facility has confirmed cases of COVID-19 among residents and staff.

Complaint investigation consisted of file review of four residents (R1 - R4), interviews with staff, and interviews with an outside agency. The department has determined the following as it relates to the allegation: Personal Rights

LPA Valerio reviewed four resident files (R1 - R4). The files reviewed were of residents who were temporarily out of the facility due to medical reasons. LPA did not observe any personal rights being violated for R1, R2, or R4. R1 was being transferred to another facility due to needing a higher level of care. R2 and R4 are being temporarily treated at higher level of care and will be welcome back once treatment is complete. R3 was transferred to another facility due to needing a higher level of care. Continues on LIC 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

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 2

Control Number 27-AS-20211021170202

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: 342700835
	VISIT DATE: 01/18/2022

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

...Continued from LIC 9099

On 09/28/2021, LPA Valerio met with previous Administrator Kevin Litterer and Clinical Lead Garret Winman due to a substantiated complaint (27-AS-20210923103802). Both individuals informed LPA they would not accept Resident 3 (R3) back because R3 reported City Creek Assisted Living to Community Care Licensing (CCL). "We already got in trouble for an illegal eviction, we mind as well not accept him back now." said by previous Administrator Kevin Litterer. LPA reminded individuals of Title 22 regulations and later agreed to take R3 back. According to the hospital R3 was receiving care, the agency was told in October of 2021 R3 will not be allowed back due to needs being higher than City Creek can manage. On 11/15/2021, LPA Valerio interview new and current Administrator Caleb Summerhays. Administrator Caleb was not aware of R3 not coming back. Administrator stated that in the recent assessment done by City Creek Assisted Living, R3's wounds were not healed. On 1/14/2022, LPA Valerio interviewed the hospital where R3 is receiving treatment. The hospital stated R3 has healed and is ready to go back, but has yet to hear from City Creek Assisted Living and was unaware of the new management change. Administrator Caleb stated R3 will be welcome back and a new assessment will be conducted to ensure R3's needs can be met with R3's current condition before approving or denying admission.

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.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to Program Director Caleb Summerhays.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2