342700835-1-20-2022-27-AS-KHOS-CB4MYH-20220128090133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 01/20/2022
Date Signed: 01/20/2022 02:15:31 PM

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
11/09/2021 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211109130810

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:	01/20/2022
		UNANNOUNCED	TIME BEGAN:	10:42 AM
MET WITH:	Caleb Summeryhays		TIME COMPLETED:	02:17 PM

ALLEGATION(S):

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Night supervision staff was not available to assist in caring for a resident during an emergency
Staff do not assist resident(s) with medications as needed

INVESTIGATION FINDINGS:

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

Complaint investigation consisted of file review of two residents (R1 - R2), file review of facility documentation, interviews with staff, and interviews with residents The department has determined the following as it relates to the allegation: Night supervision staff was not available to assist in caring for a resident during an emergency and Staff do not assist resident(s) with medications as needed

On 12/11/2021 at 7:45 PM, LPA Valerio arrived at the facility unannounced. LPA Valerio observed four medication technicians on shift, five residential aids, and two kitchen staff on shift.
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: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211109130810

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: 01/20/2022

NARRATIVE

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LPA Valerio reviewed facility files for Resident 1 (R1). On 11/06/2022, R1 fell in R1's room. R1's spouse alerted staff via call light. Staff responded and found R1 in the bathroom and unresponsive. 911 was called and CPR was done until EMTs arrived at the facility. According to staff interviews (S1 and S2), staff responded to the call light alert within minutes of R1 falling. According to Staff 3 (S3), the med tech assigned to the hall where R1 was located could not be found during the time of incident. The residential aid had to find another med tech to respond to the call. According to facility records, there were 3 Medication Technicians and 3 Residential Aids on shift when the incident occurred. According to nursing notes, R1 passed away the same evening at the hospital.

LPA Valerio reviewed facility files for Resident 2 (R2). R2 had multiple incidents during October 2021 and November 2021. Facility documentation shows that staff were present during these incidents and described how staff and management de-escalated the situation while communicating with family. R2 was sent out due to needing a higher level of care. After being treated, R2 was welcomed back.

LPA Valerio interviewed 8 staff (S1-S8). S1, S2, S3, S4, S6, S7 confirmed that staff are on shift at all times. S2, S3, S4, S6, and S7 expressed that they have experienced times where they feel they are short staffed. S5 and S8 are new staff members that were in training and did not comment on staffing. S7 stated when management knows evening shift will be short one medication technician, the morning staff will help by giving 5:00 PM medications or setting up the medication station. S1 stated if the facility has any calls offs and no on-call staff can pick up, the facility will assign medication technicians more rooms to pass medications.

LPA Valerio interviewed 2 residents (R1 and R2). R1 stated R1 gets medications all the time. R1 has lived at the facility for 6 years. R2 stated R2 gets medications when the staff come around. R2 has resided at City Creek Assisted Living for 2 years.

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 left at the facility. .

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC9099 (FAS) - (06/04)

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