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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:26:42 AM

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
07/26/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230726091832
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:
10/03/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Staff does not ensure that facility alarm system is in place, resulting in multiple dementia residents leaving unnoticed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation finding. LPA met with Administrator Caleb Summerhays, and explained the purpose of the visit.

The complaint has determined the following as it relates to the following allegation: Staff does not ensure that facility alarm system is in place, resulting in multiple dementia residents leaving unnoticed.

LPA reviewed facility records. Resident 1 (R1) left the facility during the morning of 05/19/2023. R1 called Alpha 1, a medical transport company, to be transported to the hospital. Alpha 1 drove R1 to the hospital. R1 was checked into the hospital. At 3:30 PM, the facility learned R1 was out of the community when the hospital called to obtain information regarding R1.

Continues 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: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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 8
Control Number 27-AS-20230726091832
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: 10/03/2023
NARRATIVE
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Continued from LIC 9099

According to Staff 1 (S1), Staff was unaware that R1 left during the entire morning shift. According to an interview with Resident 1 (R1), R1 was unable to recall the incident; however, R1 was able to express how one would call for help if needed.

Due to the incident, R1 was placed on alert charting and to be checked on every hour. Staff are required to sign a hourly check sheet to state the staff saw R1 inside the facility. Based on records review, NOC shift hours 10:00 PM - 6:00 AM are rarely completed. 7 out of 28 days reviewed were signed off by staff. AM Shift, 6:00 AM - 2:00 PM, filled out the hourly log 21 out of 28 days. PM shift, 2:00PM - 10:00 PM, filled out the hourly log 19 out of 28 days. Although an hourly check log has been implemented, staff do not ensure they are completing the hourly checks.

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. Failure to correct deficiencies may result in additional civil penalties. Appeal Rights provided. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20230726091832
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: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
87705(k)(6)
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87705 Care of Persons with Dementia k) The following initial and continuing requirements must be met... (6) ... facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement was not met as evidenced by:
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Licensee stated they have created an hourly check log and will conduct a refresher training. Licensee has also implemented a new alarm system for residents with dementia. Resident bracelets will cause an alarm to sound if they exit the building. LPA to receive in-service sheet by POC due date.
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Based on records review and interviews, the licensee did not ensure staff checked on all residents, resulting in R1 leaving the facility for the entire day and making it to the hospital without staff knowledge. This poses a potential health and safety risk to residents 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: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
07/26/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230726091832

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: DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Staff does not follow residents' doctors' orders.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation finding. LPA met with Administrator Caleb Summerhays, and explained the purpose of the visit.

The complaint has determined the following as it relates to the following allegation: Staff does not follow residents' doctors' orders.

On 07/09/23, Resident 2 (R2) was observed by staff to have redness under breast and groin area and an infection in the eye. Notes were written by staff regarding the status of R2 on 07/09/23, 07/10/23, 07/15/23, 07/20/23, 07/24/23, 07/25/23, and 07/30/23. Notes reveal that the resident was sent out to the hospital 4 times due to change of condition. When a new order was provided by a physician, staff wrote "new orders noted. Records also show that the facility send Unusual Incident Reports to the Regional Office.

Continues on LIC 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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 8
Control Number 27-AS-20230726091832
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: 10/03/2023
NARRATIVE
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...Continues from LIC 9099 - A

LPA reviewed July 2023 Medication Administration Records (MAR) for R2. The MAR orders match the Physician Orders provided. LPA observed MAR notes indicating when the resident was out of the facility. On the days the resident was in the facility, staff signed off for each order in the MAR. LPA attempted to interview R1; however, interview was deemed unsuccessful. Records show the facility obtained a new LIC 602 dated 07/23/23.

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 was given to Program Director Caleb Summerhays.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
07/26/2023 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230726091832

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: DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Staff does not ensure that residents are adequately fed.
Staff does not ensure that residents are properly assessed for medical issues
Staff does not ensure that residents have dental hygiene products.
Staff does not ensure that residents have bedding.
Staff does not ensure that facility is at a comfortable temperature for the residents.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation finding. LPA met with Administrator Caleb Summerhays, and explained the purpose of the visit.

The complaint has determined the following as it relates to the above aforementioned allegations.

Staff does not ensure that residents are adequately fed.
The facility was observed on 08/01/23, 08/23/23, 09/12/23, and 09/28/23. Breakfast during on visit was observed to be an egg omelette, bran muffin, fresh chopped fruit, oatmeal, coffee/tea, and juice. During lunch service, LPA observed the plating of the food. The food looked fresh, hot as evidenced by steam coming from food, and a full plate of food for each resident. Residents were observed sitting at the dinning tables, roughly about 4 per table. Staff were passing out food with gloves on. All residents were observed to have meals by 12:00 PM.
Continues on LIC 9099 - C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20230726091832
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: 10/03/2023
NARRATIVE
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...Continued from LIC 9099 - A

LPA interviewed Staff 3 (S3). S3 stated that the facility has improved over the years in regards to quality of food. S3 feels that the residents are fed well and they are given balanced meals. Residents are involved in the menu planning process. S3 stated that if the facility needs to change the menu, they are able to update it weekly. S3 stated that snacks are offered in the morning, in the afternoon, and in the evening time. Residents are able to request additional snack items while the kitchen is operating. Before kitchen staff leave for the evening, the kitchen staff will prepare sandwiches and/or leave fruit and other food options out in the dinning hall. According to an interview with a resident's family member, the family member feels the residents are fed well. The family member stated the resident has not complained of the food and the resident has lived there for many years. According to an interview with Resident 3 (R3), R3 loves the food, is able to get snacks, and has a personal fridge for after hour items.

Staff does not ensure that residents are properly assessed for medical issues

According to an interview with S2, S2 is in charge of assessing all new intakes. S2 stated there has never been any residents that have not been assessed. S2 informed LPA that if any resident needs to be sent out, they will be sent out. S2 stated the facility is constantly calling doctors to update the resident's LIC 602. According to records reviewed by LPA, records were observed to have a pre-appraisal, an updated needs and services plan, and an updated LIC 602.

Staff does not ensure that residents have dental hygiene products. Staff does not ensure that residents have bedding.

LPA observed the facility. LPA observed the cleaning supply closet, two (2) linen closets, and two (2) supply closets. LPA took pictures for reference. The cleaning supply closet was stocked with toilet paper, paper towels, cleaning supplies for the bedrooms and bathrooms. The linen closet had 3 shelves full of towels, bedding, and comfortersThe second closet also had a linen closet full of bed sheets and comforters. According to S3, S3 stated anytime a resident ask for items, the staff put the code in to get the items. It is usually fully stocked. They have a main one they use, and they have a back up supply.

Continues on LIC 9099 - C...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20230726091832
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: 10/03/2023
NARRATIVE
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...Continued from Page 2 of LIC 9099 -C

LPA interviewed residents. R4 stated bedsheets are brought by family. Any items R4 needs, the family sends it in a package. R5 stated the facility helps with the bedsheets every Tuesday. R5 was observed to have dental and hygiene products in the bathroom. R6 stated R6 does not remember when staff change the bedding, but knows that "they just do it.". R6 was observed to have hygiene supplies and dental supplies located in R6 bathroom.

Staff does not ensure that facility is at a comfortable temperature for the residents.

The facility was observed on 08/01/23, 08/23/23, 09/12/23, and 09/28/23. During each visit, the facility temperature was observed to be within the regulatory range, which is a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature.

Based on observations, interviews, and record review, the aforementioned allegations are unfounded and the allegations are false. Per California Code of Regulations, Title 22, Division 6, chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of the report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8