342700835-7-19-2022-27-AS-LKIG-CGQ572-20220726194135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 07/19/2022
Date Signed: 07/19/2022 06:10:59 PM

Unsubstantiated

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
02/15/2022 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20220215152808

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:	07/19/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Questionable death
Facility does not have appropriate signal system for residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived on 7/19/22 at 10:20am unannounced to conclude a complaint investigation. LPA met with Caleb Summerhays, Administrator and stated the purpose of the visit. On 2/16/2022, Jamie Ivey Canady and Victoria Brown arrived unannounced to the facility to open the complaint.

The investigation conducted by Community C are Licensing (CCL) revealed that there was insufficient evidence that the two residents’ deaths were a result of neglect by the facility. A review of documents indicate that R1 refused medications the day before. Interviews with the Nurse Practioner revealed that the missed medications would not be the cause of death. R2 had already been utiliing hospice services prior to date of death and there was no indication that R2 missed any medications as this was being handled by the Hospice Agency.

Unsubstantiated

Estimated Days of Completion: 60

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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-20220215152808

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: 07/19/2022

NARRATIVE

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There was not sufficient evidence that the signal system was not working during the time the complaint was received by CCL. However, the signal system was checked, and working in residents room and on the main switch board during this visit. LPA conducted interviews of residents, staff, and Administrator during this visit.

Based on records review, interviews and lack of evidence the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC9099 (FAS) - (06/04)

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