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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 09/27/2021
Date Signed: 09/27/2021 02:39:06 PM



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
09/23/2021 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20210923103802
FACILITY NAME:CITY CREEK ASSISTED LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:LITTERER, KEVINFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 599-7033
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 99DATE:
09/27/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Kevin LittererTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a 10-Day Complaint Investigation Visit. LPA Valerio was screened for COVID-19 symptoms prior to being allowed entry. LPA Valerio explained the purpose of the visit and was met by Administrator Kevin Litterer.

LPA Valerio requested facility documentation for any residents that may relate to the allegation above. Administrator named Resident 1 (R1) and Resident 2 (R2). R1 and R2's LIC 602 and Admission Agreement was provided and reviewed. The facility's Admission Agreement references Conditions for Evictions that correlate with Title 22 regulations and H&S code 1569.682. The admission agreements were signed by both residents and facility representative.

LPA Valerio interviewed the Reporting Party (RP), Mid-Town Oaks Discharge Planner, Kaiser South Sacramento Doctor, and Administrator Kevin L. at the time of the visit.
Continued on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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 3
Control Number 27-AS-20210923103802
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: 09/27/2021
NARRATIVE
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Continued from LIC 9099...

Facility administrator stated an eviction notice was not given to any residents and all resident belongings are still in their rooms. Administrator stated the facility believes R1 and R2 need a higher level of care and should not return at this time. R1's discharge planner was told the resident will need to be re-assessed to determine level of care. Administrator Kevin stated R2 did not want to return to the facility and Kaiser South is looking for another placement.

LPA Valerio interview Mid-Town Oaks Discharge Planner. On 08/30/21, Mid-Town Oaks spoke to Administrator Kevin and confirmed that R1 would be able to return to the facility once he is better. Mid-Town Oaks stated that City Creek Assisted Living would not allow R1 to return to the facility on 09/15/21 due to wounds being higher than a stage 1 or 2. On 09/24/21, Mid-Town Oaks was told R1 could not come back to the facility due to needing a higher level of care. an assessment needed to be done. Mid-Town Oaks says R1 is ready to be discharge and wounds have healed. Mid-Town Oaks stated R1 does not quality for long-term care there. Mid-Town is waiting for assessment to be done by City Creek Assisted Living.

LPA Valerio attempted to interview Kaiser South Sacramento doctor. The doctor told LPA Valerio not to call him regarding this matter. Interview was deemed unsuccessful.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.  California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.

An exit interview was conducted, and a copy of the report was provided to Administrator Kevin Litterer .
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210923103802
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: 09/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2021
Section Cited
CCR
87224(c)
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87224 Eviction Procedures
(c)The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident... This requirement was not met as evidenced by:
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The licensee stated effective immediately all residents needing a higher level of care will have supporting documents that meet requirement 87224 prior to a eviction. Supporting documents will include progress notes, an updated assessment of resident, and a call communication log with outside health facilities.
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Out of the 4 interviews conducted, 2 interviews confirmed R1 was in the process of being evicted from the facility. Based on interviews and record review, the licensee did not ensure 1 out of 2 residents endured proper eviction protocols. This poses a potential 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: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3