342700835-5-19-2022-27-AS-SRIN-CEZT3U-20220602142255

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 05/19/2022
Date Signed: 05/19/2022 02:15:09 PM

Substantiated

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
04/05/2022 and conducted by Evaluator Jamie Ivey-Canady

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220405153605

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: 102	DATE:	05/19/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility does not provide medications to residents as prescribed
Facility does not have enough staff
Non-skilled professionals are providing insulin injections to residents
Facility does not meet needs of residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)s Jamie Ivey Canady and LPA Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Caleb Summerhays.

The investigation was conducted by LPA Ivey Canady and consisted of interviews with residents, interviews with staff, and review of resident files.

The Department has determined the following as it relates to the allegations: Facility does not provide medications to residents as prescribed, Facility does not have enough staff, Non-skilled professionals are providing insulin injections to residents, Facility does not meet needs of residents.

Continued on LIC 9099 - C...
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220405153605

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: 05/19/2022

NARRATIVE

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LPA Ivey Canady interviewed 4 staff. 4 out of 4 staff members admitted to LPA Ivey Canady residents did not receive their medications. According to interview, S3 stated the facility has gone as long as 2 weeks without proper medications to administer to residents.According records reviewed, LPA Ivey Canady observed several occasions whereas residents did not receive medications with annotations of "waiting on pharmacy". According to records review LPA observed residents did not receive medications over a course of weeks at a time.LPA Ivey Canady interviewed 6 residents. 3 out 6 residents indicated they have missed doses of medications. This allegation is substantiated and has also been cited on complaint control number 27-AS-20220210154551

According to interview with S3, there is not enough staff to cover the shifts and medications are not being properly disbursed because of this. According to interview with S4, staff who no longer work at the facility are being listed on the schedule to work. Because staff that no longer work at the facility are scheduled to work specific shifts, and are a no show, residents are going significant amounts of time without their proper dosages of medications. This causes a health and safety concern to the residents and is in violation of Title 22 regulations.

Facility administrator stated he was unaware of residents being administered insulin by unskilled staff. According to interview with S2 and S3 both report knowledge of untrained staff administering insulin. According to interview with S2, S2 provides specific details regarding the reasons why untrained staff are administering insulin. According to interview with S2, those details include residents insisting to have assistance from staff administering their insulin, stating they are unable to do it themselves. According to interview S2, S2 stated untrained staff are administering insulin to residents.

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SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220405153605

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: 05/19/2022

NARRATIVE

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Continued from page 2...

According to interviews with S2, residents that are confined to wheelchairs are not being tended to in a timely fashion when asking for assistance. S2 stated residents in wheelchairs ask for assistance from staff and staff are too busy filling in for missing staff that there is no time to attend to request of wheelchair residents in a timely fashion. This allegation is substantiated and has also been cited on complaint control number 27-AS-20220210154551

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. 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 Administrator Caleb Summerhays .

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SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20220405153605

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
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 CCR 87629(b)(1)	1 2 3 4 5 6 7	87629 Injections (b)...the licensees who admit or retain residents who require injections shall be responsible for the following:(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated facility will offer continued training to MedTechs regarding administering medications to residents and provide a documented statement to LPA by COB 5/20/2022.
	8 9 10 11 12 13 14	Based on interviews and record review, licensee did not ensure appropriately skilled professionals were administering injections, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 05/20/2022 Section Cited CCR 87465(1)(a)	1 2 3 4 5 6 7	87465(1)(a) Incidental Medical and Dental CareA plan for incidental medical and dental care shall be developed by each facility…(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated the facility will submit an LIC500 to LPA by COB 5/20/2022.
	8 9 10 11 12 13 14	Based on interviews and records review the licensee did not ensure 1 out of 2 residents needs were met which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
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

LIC9099 (FAS) - (06/04)

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