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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:59:03 PM

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:LITTERER, KEVINFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 599-7033
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 107DATE:
09/21/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kevin LittererTIME COMPLETED:
02:38 PM
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On 09/21/21, an office meeting was conducted via Microsoft Teams, a webcam application, due to COVID-19 precautionary measures. The purpose of the meeting was to discuss a summary of Healthcare Associated Infections (HAI) Program visit, which was conducted on 09/14/21.

Participants of Meeting:
Community Care Licensing (CCL) - Sacramento South Regional Office
    - Krystall Moore, Regional Manager
    - Stacy Barlow, Assistant Administrator
    - Stephen Richardson, Licensing Program Manager
    - Christina Valerio, Licensing Program Analyst
Sacramento County Public Health
    - Melody Law, Deputy Health Officer
    - Dr. C. Jean Ogborn, Physician
    - Dr. Olive Kasirve, Health Officer
    - Pam Abdali, PHN
    - June Nash, Nurse Supervisor
California Department of Public Health (CDPH)
    - Deweese Quigley, Health Inspector for CDPH for HAI Program
City Creek Assisted Living
    - Kevin Litterer, Administrator
    - Cora Ciobanu, Nurse Supervisor and Infection Prevention Lead

Continued on LIC 809- C...
Page 1 of 2.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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
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: 09/21/2021
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As of today, the facility has 44 positive residents, of which 42 have cleared and 1 death, and 4 positive staff, of which 4 have cleared and 0 deaths.

Participants in the meeting discussed the summary of the HAI visit while working with Administrator Kevin to create a plan to address the COVID-19 outbreak.

The facility has implemented a yellow zone for all residents, implemented additional screening vitals for residents, increased reminders to residents to wear masks at all times and to stay in their rooms, increased the amount of hand sanitizer available for residents and staff, and reached out corporate officer for additional support.

The facility is to submit the following by close of business on 09/22/21:
    - Plan for housekeeping to increase sanitation of common touch surface areas and cleaning
    - PPE Burn Rate Calculation
    - Date of FIT Testing for Staff to meet OSHA requirement
    - Confirmation of facility plan to reach out to Medical Reserve Corporation for additional resources.

Exit interview held and a copy of the report was sent to Administrator Kevin Litterer to sign on the hard copy.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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