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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 11/17/2022
Date Signed: 11/18/2022 07:51:13 AM


Document Has Been Signed on 11/18/2022 07:51 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 LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:CALEB SUMMERHAYSFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 109DATE:
11/17/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melina DearingTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived to the facility unannounced and met with Melina Dearing and explained the reason for the visit.

LPA received notification from R1 family member regarding possible lack of care in relation to R1 Continuous Positive Airway Pressure (CPAP) use. LPA requested and received resident file for R1. LPA verified R1 CPAP information is the same as received from facility via email on 11/09/2022.

LPA requested and received facility Plan Of Operation, facility chart notes regarding phone conversations with R1 physician's office about R1 refusal to use CPAP machine. LPA requested and received correspondence documentation between facility and R1 family member. LPA reviewed Plan Of Operation medication refusal policy. In accordance with facility Plan Of Operation in regard to medication refusal, facility is in compliance with services facility provides.

According to facility LVN facility has reappraised R1, LVN states R1 is currently at highest level of care in accordance with facility Plan of Operation and services provided. LVN stated R1 is currently on hopice for a different diagnosis that does not pertain to CPAP use and provided LPA with a copy of R1 hospice documentation. R1 was placed on hospice care by physician on 11/08/2022. Facility is licensed for 3 hospice residents and currently have 2. LPA attempted to interview R1 and R1 is currently sleeping.

According to staff interviews and medical documentation, facility is in compliance with Title 22 regulations regarding care and services provided to R1.


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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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