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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 05/18/2022
Date Signed: 05/20/2022 02:41:17 PM


Document Has Been Signed on 05/20/2022 02:41 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: 0DATE:
05/18/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Meeting AttendeesTIME COMPLETED:
03:00 PM
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On 05/18/2022 at 2:00 PM, an Informal Meeting  was conducted on this day in the Sacramento South Regional Office via Microsoft Teams. The purpose of this Informal Meeting  was to discuss the citations that has been issued in the last 12 months. 

Present in the meeting representing Community Care Licensing Sacramento South, was Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Christina Valerio, and  Licensing Program Analyst (LPA) Jamie Ivey Canady. Representing City Creek Assisted Living was Administrator Caleb Summerhays and Co-Owner Ryan Williams.

Licensing Program Manager (LPM) Stephen Richardson explained the purpose of the meeting to include the potential administrative process. From 10/22/2021 to 1/13/2022, CITY CREEK ASSISTED LIVING has been cited 3 type A and 7 type B deficiencies. 

Issues discussed during the meeting were:
Administrator Qualifications and Duties
Basic Services
Fire Safety
Eviction procedures
Incidental Medical and Dental Care
Reporting Requirements
Resident Records
Capacity
Personal Rights

See Cont 809-C
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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: 05/18/2022
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The facility has stated they will do the following to achieve continued and improved compliance:
    -Licensee to send updated LIC308 by COB 5/20/2022
    -Licensee to hire additional staff for caregivers and medications technicians positions
    -Licensee to send quarterly service agreement contract for fire safety maintenance by COB 5/20/2022
    -Licensee to follow Title 22 Regulations regarding eviction procedures
    -Licensee to conduct medication training, medication audit training and reporting requirements training on May 25, 2022. Sign in sheet of staff attendance will be sent by COB 5/25/2022
    -Licensee to ensure sufficient number of staff to meet needs of residents
    -Licensee to ensure Administrator on site for 40 hours minimum.
    -Licensee to send updated LIC500 biweekly to Department fax until further notice

Licensee has agreed to participate in CCLD's TSP Program

  CCLD will do the following: 
· Increase Monitoring
· Technical Support Program (TSP) - LPM Richardson to send TSP referral by COB 5/19/2022

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit.  An exit interview was conducted with Administrator Caleb Summerhays and Licensee Ryan Williams. A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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