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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 01/24/2023
Date Signed: 01/24/2023 11:06:02 AM


Document Has Been Signed on 01/24/2023 11:06 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: 107DATE:
01/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Melina DearingTIME COMPLETED:
10:30 AM
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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 via Incident Report from facility regarding a restraining order that was filed by Sacramento County on 11/16/2023 against person's who calls themselves family of Resident 1 (R1). According to Staff 1 (S1), the restrained are not family of R1. The purpose of the restraining order is to keep the restrained from removing R1 from the facility.

According to S1, the Restrained was successful in getting a power of attorney when R1 was in no position to make that decision. According to S1, R1 would attempt to go visit the restrained and the facility has had to retrieve R1 from the apartment.

According to S1 the current status is that R1's conservator is attempting to relocate R1 from the facility to another facility because of the proximity of the facility to the restrained.

S1 stated the facility is currently in the process of securing a wander guard system to help with the security of R1 and all residents.





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 Melina Dearing.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
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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