342700835-8-30-2023-27-AS-KHOS-CX5QJT-20231031121314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:30:47 PM

Unsubstantiated

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
01/30/2023 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20230130141811

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: 104	DATE:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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- Staff do not distribute residents' medications as prescribed.
- Staff do not assist residents with bathing.
- Staff do not assist residents with grooming.

INVESTIGATION FINDINGS:

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On 8/30/23, at 10:15am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at the facility unannounced to continue to conduct a complaint investigation regarding the allegations noted above. LPAs originally met with Administrator Caleb Summerhays and stated the purpose of this visit. LPAs initially opened by LPA Jamie Ivey Canady on 4/13/2023. LPAs Bilger and Villanueva conducted a follow up visit on 8/18/23.

Throughout this complaint investigation, LPAs interviewed staff members including med techs and Health Services Coordinator. LPAs conducted resident record reviews and interviewed 3 current residents in care. LPAs also conducted facility observation. Additionally, LPAs conducted medication audits of 3 current residents and observed medication passing of one resident.

{Con't to LIC9099-C}

Unsubstantiated

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: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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-20230130141811

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: 08/30/2023

NARRATIVE

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{Con't from LIC9099}

Regarding the allegation: Staff do not distribute residents’ medications as prescribed. LPAs reviewed residents’ medication administration record (MAR) for January 2023 and conducted medication audits of 3 residents in care during today’s visit to determine that medications are being given as prescribed. LPAs also interviewed current residents in care and observed medication passing. Based on record reviews, it was revealed that the medications on the MAR have been consistently given to residents in care during the month of January 2023. Based on residents’ interviews conducted and medication audit, it was revealed that current residents in care are receiving their medications routinely and when needed. LPAs observed resident being given medication(s) on a timely manner during medication passing. Based on record reviews, interviews and observations, it is determined that the preponderance of evidence standard has not been met, therefore, this allegation is UNSUBSTANTIATED.

Regarding the allegation: Staff do not assist residents with bathing. LPAs conducted resident interviews as noted above and conduct additional facility observation. LPAs also reviewed resident care plans. Based on observation of facility and residents, LPAs did not observe foul odors to indicate lack of bathing during observation. Additionally, residents’ skin appeared to be free of dirt and they appeared clean in appearance. Based on interviews of current residents, it was determined that residents in care are receiving bathing assistance from staff. Based on record reviews, residents in care have care plans which include bathing and dressing, as well as documentation indicating bathing and dressing were performed. As a result, there is not a preponderance of evidence to conclude resident is not receiving regular bathing assistance, and this allegation is UNSUBSTANTIATED.

{Con't to LIC9099-C}

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20230130141811

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: 08/30/2023

NARRATIVE

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{Con't from LIC9099-C}

Regarding the allegation: Staff do not assist residents in grooming. LPAs conducted resident interviews as noted above and conducted additional facility observation. LPAs also reviewed resident care plans. Based on observation of facility and residents, LPAs observed resident's appearance do not indicate lack of grooming during observation. Residents observed appeared to be well-groomed: nails cut, hair is combed, wearing appropriate clothing based on current weather conditions, and face clean shaven. Based on interviews of current residents, it was determined that residents in care have been receiving grooming assistance from staff. Based on record reviews, residents in care have care plans which include grooming assistance as well as documentation to indicate grooming assistance is performed. As a result, there is not a preponderance of evidence to conclude resident is not receiving regular grooming assistance, and this allegation is UNSUBSTANTIATED.

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

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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