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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 05/19/2022
Date Signed: 05/19/2022 01:59:09 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
02/10/2022 and conducted by Evaluator Jamie Ivey-Canady
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220210154551
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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Residents do not receive medications as prescribed.
Staff did not transport the resident to the VA hospital.
Staff provide residents with inappropriate medical supplies.
Resident's needs are not being met while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s Jamie Ivey Canady and 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. The investigation 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: Residents do not receive medications as prescribed. Staff did not transport the resident to the VA hospital. Staff provide residents with inappropriate medical supplies. Resident's needs are not being met while in care.

Continued on LIC 9099 - C...
Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 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)
Page: 1 of 4
Control Number 27-AS-20220210154551
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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According to interview, S4 stated the facility has gone as long as 2 weeks without proper medications to administer to residents. According records review, LPA 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. According to interview with S4, there are times when staff schedules do have employees listed on the schedule that are no longer working at the facility. According to interview, it takes 2-3 days for the schedule to be re-created. When this happens and  there is a shift change, there is no one there to pass medications to residents, therefore residents do not receive medications as prescribed which poses a health and safety violation.

According to interview with Administrator, the facility is not responsible for transportation to the VA hospital. Administrator is aware of several residents consistently requesting to be transported to the VA hospital. According to interview with R1, R1 requested on several occasions for assistance for transportation to the VA hospital, to no avail. R1 described a health and safety matter of not having an appetite that R1 felt the VA hospital could provide specialized care to help and was denied service to the VA by the facility.

According to interview with staff, staff are providing residents with syringes that are the wrong size. According to interview with S2, there is knowledge by the facility staff of untrained staff providing insulin to residents with the wrong size syringe. According to interview with S2, S2 heard that other staff were using the wrong size syringe but did not confirm it with LPA.

According to interviews with S4, residents that are confined to wheelchairs are not being tended to in a timely fashion when asking for assistance. S4 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.

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
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 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: 2 of 4
Control Number 27-AS-20220210154551
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
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4)The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by:
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Licensee states facility will provide appropriate medical supplies to residents. Licensee will provide photographs or receipts of the correct medical supplies to LPA by COB 5/20/2022
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Based on interviews and records review the licensee did not ensure 3 out of 6 residents did not received medications as prescribed, which poses an immediate health and safety risk to persons in care.
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Type B
06/10/2022
Section Cited
CCR
87464(f)(6)
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87464 Basic services (f) Basic services shall at a minimum include...(6)Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by:
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Licensee states facility will provide additional staff by doubling caregiver staff and providing LPA a copy of LIC500 by COB 6/10/2022.
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Based on interviews and records review the licensee did not provide arrangements for transportation for 1 out of 2 residents to the medical facility of personal choice. This poses a potential health and safey risk to persons in ca
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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: Jamie Ivey-CanadyTELEPHONE: 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)
Page: 3 of 4
Control Number 27-AS-20220210154551
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)(2)
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87629 Injections (b)...the licensees who admit or retain residents who require injections shall be responsible for the following:(2) Ensuring that sufficient amounts of medicines, test equipment, syringes, needles and other supplies are maintained in the facility.. This requirement was not met as evidenced by:
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Licensee states the goal is to increase 4 MedTechs per shift and 8 caregivers pershift. Licensee to send updated LIC500 to LPA by COB 5/20/2022
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Based on interviews with staff and residents, licensee did not ensure residents were equiped with the appropriate medical equipment, which poses an immediate health and safety risk to residents in care.
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Type A
05/20/2022
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each5/20 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:
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Licensee states the facility will provide provisions for transportation of residents as a back alternative to residents when no other resources are available. Licensee to send statement of procedure to LPA via email by COB 5/20/2022.
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Based on interviews with staff and residents, residents in wheelchairs are not having requested assistance in a timely fashion, which poses an immediate health and safety risk to persons in care.
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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: Jamie Ivey-CanadyTELEPHONE: 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)
Page: 4 of 4