342700835-8-16-2023-27-AS-RWAE-CURRSW-20230816131725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:17:28 PM

Document Has Been Signed on 08/16/2023 01:17 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 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:	08/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Caleb Summerhays - Administrator		TIME COMPLETED:	12:25 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) Ruth Wallace conducted unannounced Required - 1 Year Annual visit. LPA met with Administrator and discussed the purpose of the visit. Administrator Certificate expires 11/17/23. The facility is licensed for a capacity of 121 residents. There are no residents receiving hospice services at this time. The temperature inside the facility was observed to be at 72F which is within the required range of 68-85F. The hot water temperature was measured at 111.6F which is within the required range of 105-120F. LPA observed a pull alarm system, fire extinguisher(s) last inspected on July 23, 2023, smoke and carbon monoxide detectors, and central heating and air in the facility. All Fire Exits are free of obstacles and last fire drill was completed on July 20, 2023. LPA observed two day perishables and seven day non-perishables. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items. LPA reviewed five staff and five resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility. Facility has begun renovation of facility. All common areas, hallways, dining room, etc. will be completed. New flooring and baseboards for all resident rooms. Interior painting and repair of walls. New flooring throughout building and new cabinetry in front reception and old nurse's station towards the back of building. New lighting throughout building. The project will take approximately eight months up to a year. Each resident is aware of renovation and six beds will be open for temporary relocation when residents' rooms are being updated. All work is being completed by licensed contractors. Continued on 809-C Page 2

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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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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: 08/16/2023

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Continued from 809 - Page 2

Facility is installing a wander guard system to help monitor exit seeking residents.

LPA received the following updated documents for master file in CCL on today's date:
Designation of Facility Responsibility (LIC 308), Administrative Organization (LIC 309), Personnel Report (LIC 500), Emergency Disaster Plan (610E), Liability Insurance, and Administrator Certificate.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited.

Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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