<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 05/19/2022
Date Signed: 05/19/2022 01:41:20 PM


Document Has Been Signed on 05/19/2022 01:41 PM - It Cannot Be Edited

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 LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:CALEB SUMMERHAYSFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 102DATE:
05/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
02:00 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
Licensing Program Analyst (LPA) Christina Valerio and LPA Ivey Canady arrived to the facility unannounced to conduct a case management visit to follow up on an incident report received regarding a resident that had left the facility without the knowledge of staff. LPAs met with Administrator Caleb Summerhays and explained the purpose of the visit.

According to the incident report submitted, facility staff discovered that Resident 1 (R1) was not in the building. Staff conducted a building search and confirmed the resident was not in the building or surrounding areas. Later in day, the facility received a call from an officer stating the resident was in Natomas, CA and transferred to Sutter Hospital. R1 returned from the hospital later that day with no noted injuries. LPAs reviewed Resident 1 (R1) LIC 602 Physician's Report, which states that the resident is not able to leave the facility unassisted.

Based on the above mentioned information, deficiencies were observed and can be found on LIC 809-D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted, and a copy of the report was provided to facility staff Caleb Summerhays.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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


Document Has Been Signed on 05/19/2022 01:41 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited

1
2
3
4
5
6
7
87464 Basic Services (f) Basic services shall...include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code 2(c). This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not ensure R1 did not leave the facility unassisted, which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2