342700835-7-21-2023-27-AS-SRIN-CURRLE-20230816130700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 07/21/2023
Date Signed: 07/21/2023 12:26:42 PM

Substantiated

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
04/24/2023 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20230424115149

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:	11:00 AM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Resident sustained multiple unexplained injuries while in care due to lack of staff supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at the facility unannounced to deliver complaint investigation findings. LPAs met with Caleb Summerhays and explained the reason for the visit.

The Department conducted an investigation consisting of Facility File Review, Facility Records Review, Medical Records Review, Staff Interviews, and Resident Interviews. The Department has determined the following as it relates to the above allegation: Resident 1 (R1) sustained multiple unexplained injuries due to lack of staff care and supervision.

Based on department interviews, Facility Executive Director, Director of Health Services, and Resident Care Director did an internal investigation and determined Staff 1 (S1) was not performing duties as a caregiver and failed to do checks on R1.

Substantiated

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-20230424115149

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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Reviews of Medical Records concluded that R1 sustained injuries consistent with a fall and being left unattended for an extended period of time.

Interview with the attending Medical Doctor (MD) determined that R1’s injuries were consistent with someone who had a fall and was left unattended for close to eight hours.

Based on records review, and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, citations for deficiencies can be found on the LIC 9099 -D. An immediate civil penalty of $500 is issued in addition to citation due to injury related to violation of Section 1569.312(e). Failure to correct deficiencies may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was held, and a copy of the report provided. Appeal Rights provided.

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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Control Number 27-AS-20230424115149

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/24/2023 Section Cited HSC 1569.312(e)	1 2 3 4 5 6 7	1569.312 Basic services requirement. Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.	1 2 3 4 5 6 7	Administrator to submit a plan in place to ensure residents are being checked regularly. Plan to be submitted to the Department by the POC date.
	8 9 10 11 12 13 14	This was not met as evidenced by: Based on interviews and record reviews, the facility licensee did not ensure care and supervision (including regularly checking residents) to R1 while in care at the facility which resulted in R1 sustaining multiple injuries consistent with a fall and was left unattended for a extended period of time.	8 9 10 11 12 13 14	Administrator to submit staff training on resident monitoring. Proof of training date be submitted by POC date and proof of completed training be submitted to the Department within 15 days after the training date.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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