342700835-7-21-2023-27-AS-SRIN-CUR7S5-20230815215434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 07/21/2023
Date Signed: 07/21/2023 04:50:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2023 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20230314163836

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:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility administered the incorrect medication to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to the facility on 07/21/2023 and conducted the investigation at 12:25pm regarding the allegation noted above. LPAs met with Caleb Summerhays and stated the purpose of this visit.

Complaint investigation consisted of file review of resident 1 (R1), and interviews with Staff 1 (S1). The Department has determined the following as it relates to the above allegation. LPAs interviewed S1 and indicated that R1 was taken to the hospital on 1/29/2023 due to swollen leg and R1 never returned back to the facility.

LPAs reviewed R1's most recent physician's orders, medication administration record (MAR) from November 2022 to January 2023, charting notes, and incident report on 1/29/23. LPAs found that R1's medications on the physciian's orders match on what is on the MAR.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230314163836

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CITY CREEK ASSISTED LIVING	FACILITY NUMBER: 342700835
	VISIT DATE: 07/21/2023

NARRATIVE

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Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report and appeal rights were provided to the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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