342700835-10-17-2022-27-AS-JICY-CKAL2R-20221017082242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 10/14/2022
Date Signed: 10/17/2022 08:22:50 AM

Document Has Been Signed on 10/17/2022 08:22 AM - 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 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: 106	DATE:	10/14/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced regarding the incident report dated 10/11//2022 submitted to the Department. LPA Ivey Canady met with Administrator Caleb Summerhays and explained the purpose of today's visit. On 10/11/2022, an incident occurred at the facility. There was a resident to resident altercation that resulted in R1 hitting R2. R1 and R2 were waiting in line for lunch. According to the report, R1 assumed R2 was speaking directly to R1 and was making insults, at which point R1 hit R2. According to the incident report, R2 did not sustain an injury and no medical attention was necessary. The licensee/administrator informed the responsible party and Community Care Licensing within hours of the incident. LPA Ivey Canady interviewed the administrator, R1, R2 and facility nurse regarding the incident. Facility nurse states the facility ensures R1 and R2 remain separate at all times. Facility Nurse states there was a full skin check on R2 the same day and the next day to ensure no injury appeared. LPA Ivey Canady inquired the status of the injured resident and administrator reports the family came to the facility to assess R2 and was satisfied there was no injury. Administrator stated no police were called and no police report was made due to no injury being sustained. LPA Ivey Canady interviewed R2 and observed no injury. Administrator stated residents are never left unattended for more than 30 minute intervals and residents are always walking the halls and visible to staff during the day. Cont 809-C

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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: 10/14/2022

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During interview with R1, R1 stated R2 was laughing which caused the reaction. R1 stated both residents are staying apart from one another. Since the incident, there has been no additional occurrences regarding R1 and R2.

During interview with R2, R2 stated there was a understanding that R1 did not realize what was happening and R2 is fine. R2 reports having no injuries.

LPA Ivey Canady requested and reviewed resident files of R1 and R2. There are no 1:1 designations for either resident.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was given to Administrator Caleb Summerhays.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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