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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:01:35 PM


Document Has Been Signed on 10/25/2023 04:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
10/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/25/2023, at 3:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at the facility unannounced to conduct a case management visit. LPAs met with Administrator Caleb Summerhays and stated the purpose of this visit.

The Department received a fax from City Creek on 8/22/23 regarding Resident_1’s (R1) blood pressure medication. Per review of the faxed document indicated that R1 was taking a prescribed blood pressure medication requiring blood pressure reading prior to self-administration. Further review of the faxed document indicated that it was addressed to R1’s physician in which the facility requesting for the prescription order to change without the need to take blood pressure reading prior to self-administration. Interview with Staff_1 (S1) on 8/30/23 reveal that the fax was sent to the Department accidentally and it was meant to be faxed to R1’s physician. Per interview with S1 it was also revealed that during their recent medication inventory of all facility residents’ medication, staff discovered an oversight on R1’s medication requiring a vital sign reading prior to self-administration. S1 informed LPAs that med techs who are not appropriately skilled professionals have been assisting R1 with blood pressure medication and taking R1’s blood pressure readings. LPAs also conducted medication audits and observed medication passing of random residents in care on 8/30/23.

Based on records reviews and interviews, there is a preponderance of evidence to conclude that staff inappropriately assisted R1 with self-administration of medications. Per California Code of Regulations Title 22, Division 6, Chapter 8) citations for deficiencies can be found on the LIC 809-D.

An immediate civil penalty of $250 is issued in addition to citation due to repeat violation. Failure to correct deficiencies may result in additional civil penalties.

An exit interview was conducted with Administrator Caleb Summerhays and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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Document Has Been Signed on 10/25/2023 04:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
87465(a)(4)

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87465(a)(4) The licensee shall assist residents with self-administered medication as needed.

This was not met as evidenced by:
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Licensee to review RCFE medication guide from the technical support resource guide and submit declaration of understanding to the Department by POC due date
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Based on record reviews and interviews, licensee did not ensure R1’s blood pressure medication was being administered appropriately. This poses a potential health and safety risk to person 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) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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