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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:06:52 PM


Document Has Been Signed on 10/26/2023 03:06 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: 108DATE:
10/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to conduct a case management regarding a discovery during a complaint investigation in reference to complaint number 27-AS-20230522082455. LPA Ivey Canady met with administrator Caleb Summerhays and explained the purpose of the visit.

During the investigation for complaint number 27-AS-20230522082455 it was learned R1 has been diagnosed with dementia and as such is unable to conduct personal financial business. Based on this information, LPA conducted a interview with administrator Caleb Summerhays, and the facility has decided to pursue payee services for R1. Furthermore, according to the administrator, the facility will continue transactions for all residents using a payee service or conservator as needed.

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 provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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