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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 11/01/2022
Date Signed: 11/01/2022 03:28:37 PM


Document Has Been Signed on 11/01/2022 03:28 PM - 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 LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:CALEB SUMMERHAYSFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 109DATE:
11/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Deborah GagleTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady and Licensing Program Manager (LPM) Stephen Richardson arrived to the facility unannounced and met with Deborah Gagle and explained the reason for the visit.

On 10/25/2022, Community Care Licensing (CCL) received a SOC341 regarding possible neglect. LPA Ivey Canady requested and received a copy of Resident 1 (R1) resident file. R1 has been at the facility for 4 weeks. According to Staff 1 (S1), R1 had a seizure due to low magnesium and was sent to the hospital. When R1 was returned to the facility, it was determined by R1 family and facility LVN that R1 needs a higher level of care. Based on that decision, the facility is working with Star Agency in regards to facilitating a new placement facility for R1.

S1 stated R1 placement was represented at a lower level of care that R1 actually needs. Therefore the need for R1 replacement to a different facility is justified.

According to further investigation, R1 suffered a seizure on 10/18/2022. CCL was not notified via incident report of the occurrence. LPA Ivey Canady received a copy of the incident report during this unannounced visit on 11/1/2022.

During facility visit it was discovered current designated person in charge of the facility is fingerprint cleared but not associated to this facility. The identification number was provided to human resources at the time of hire. Based on this discovery current person in charge was removed from staff schedule as of 11/01/2022 and deficiencies cited. Civil penalties will be assessed.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, . An exit interview was held, and due to printer malfunction a copy of the report and appeal rights were emailed to Deborah Gagle.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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 3


Document Has Been Signed on 11/01/2022 03:28 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2022
Section Cited

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87211 Reporting Requirements(a)Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(B)Any serious injury as determined by the attending physician...This requirement was not met as evidenced by:
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Based on interviews and record review, the licensee did not ensure residents medical occurence was reported to Community Care Licensing per Title 22 Regulations. This poses a potential health and safety risk to residents in care.
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Type B
11/01/2022
Section Cited

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87355 Criminal Record Clearance(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidenced by:


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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: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/01/2022 03:28 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2022
Section Cited

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87411 Personnel Requirements (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement was not met as evidenced by:
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Based on records review, interviews, and observation, the licensee did not ensure staff 2 maintained an active first aid certification which poses an immediate health, safety, or personal rights risk to residents 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: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3