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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 02/06/2023
Date Signed: 02/06/2023 03:34:35 PM

Substantiated


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
08/03/2022 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20220803093938
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: 106DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility did not notify family or CCL of incidents
Facility neglected resident causing resident to obtain ulcer wound
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Caleb Summerhays.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with staff, interviews with witness, review of resident medical files and review of resident files.

The Department has determined the following as it relates to the allegations: Facility did not notify family or CCL of incidents. Facility neglected resident causing resident to obtain ulcer wound.

Continued on LIC 9099 - C...
Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20220803093938
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: 02/06/2023
NARRATIVE
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On 11/01/2022, 12/01/2022 and 12/02/2022 LPA Ivey Canady requested and reviewed medical documents, performed file review, performed Community Care Licensing (CCL) incident document search, and interviewed witness. On 11/01/2022, LPA requested all incident report documents from facility dated back 6 months. Based on this request and review, CCL did not receive an incident report regarding R1 ulcer wound. According to record review, on 8/11/2022, facility documented treating an ulcer wound on R1. Based on witness statement, document reviews, medical document reviews, interviews with witness, CCL incident document search, and documentation submitted by witness, the facility failed to report R1 pressure injury status to Community Care Licensing (CCL) and R1 responsible party as directed in Title 22 Regulations. Therefore, the allegation Facility did not notify family or CCL of incidents is Substantiated.

Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Administrator. Appeal rights and report given

On 12/2/2022, LPA discovered during continued interviews with RP, R1 was transferred from Skilled nursing in July 2021 to this facility. According to medical record review, facility chart notes, staff files and interviews with facility staff, R1 was being treated for a pressure injury on 9/1/2022 and did not come to the facility with the ulcer wound in July 2021. R1 has not been residing at any other location but this facility since admission. Based on review of medical files, chart notes and staff interviews, R1 has a diagnosis of pre - diabetes. Based on resident medical record review and Department consultation with licensed medical professional R1 ulcer wound is not related to pre-diabetes. According to review of medical reports, physician reports and staff interviews, R1 developed an ulcer wound while in the care of the facility. Therefore, the allegation; Facility neglected resident causing resident to obtain ulcer wound is Substantiated.

Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.


Exit interview with Administrator. Appeal rights and report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220803093938
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2023
Section Cited
CCR
87211(a)(B)
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Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports as the Department may require...(B)Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This was not met as evidenced by:
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Licensee stated the facility will ensure there is a policy and procedure in place for incident reporting guidlines and provide LPA a copy of the policy no later than 2/7/2023.
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Based on facility and Department record review the Licensee did not ensure a pressure injury/ulcer wound was reported to the Department as required in Title 22 Regulations. This poses an immediate health and safety risk to persons in care.
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Type A
02/06/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,...(4)To care, supervision, and services that meet their individual needs....This was not met as evidenced by:
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Licensee stated the facility will a pressure wound policy and procedure and provide in service training to staff within 24 hours and provide LPA a copy of staff training sign in document no later than 2/2/7/2023.
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Based on medical record review, the licensee did not ensure residents in care did not develop ulcer wounds and or pressure injuries. This poses an immediate health and safety risk to persons 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: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/03/2022 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20220803093938

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: 106DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Facility is not following physican's orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Caleb Summerhays.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with residents, interviews with staff, interviews with witness, review of resident medical files and review of resident files.

The Department has determined the following as it relates to the allegations: Facility is not following physician's orders

Cont on 9099-C
Page 1 0f 2
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220803093938
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: 02/06/2023
NARRATIVE
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On 11/21/2022 LPA Ivey Canady visited the facility and met with facility administrator. LPA requested and received staff chart notes, medical files, and resident files for R1, R2 and R3. According to review of medical files, R1 attended all appointments as scheduled. According to review of staff files and chart notes, R1, R2 and R3 were given medications as prescribed. Based on detailed documentation by the facility, LPA reviewed evidence of efforts by the facility to provide R1 with prescribed medical assistance with medical equipment, daily as prescribed. However, on each daily prescribed occasion R1 refused the use of prescribed medical equipment. Subsequently, facility fulfilled Title 22 regulations regarding providing medical assistance as prescribed. Therefore, the allegation Facility is not following physicians orders is UNFOUNDED.

Due to the information gathered LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview held and a copy of the report was provided to Administrator Caleb Summerhays via email due to printer malfunction.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5