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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:03:02 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
01/30/2023 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20230130141811
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:
10/25/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained a pressure injury while in care.
INVESTIGATION FINDINGS:
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On 10/25/2023, at 10 am, 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 met with Administrator Caleb Summerhays and stated the purpose of this visit.

Throughout this investigation, LPAs interviewed staff members and reviewed R4’s files, including resident charting notes, resident care plans, activity of daily living (ADL) notes, Home Health notes, and resident physician orders.

Regarding the allegation, resident sustained a pressure injury while in care, the licensee did not demonstrate evidence that pressure wound was monitored adequately and timely. Review of Resident_4 (R4) charting notes and home health notes indicated that R4 was observed to have an open sore on the coccyx area on 5/25/23. On 5/31/23, charting notes indicate that the wound is worsening.
{Con't on 9099-C}
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
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: 10/25/2023
NARRATIVE
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R4 was sent to hospital on 5/31/23 and returned to the facility on 6/1/23 and the pressure wound was assessed to stage 2. Based on an interview with Staff_1 (S1), there was no evidence between 5/25/23 and 5/31/23 to address the care of R4’s pressure wound. Based on record review and interview with S1, there was no evidence to indicate adequate care and monitoring was provided to the R4’s wound between 6/1/23 and 6/8/23. Based on record review, Home Health Agency assessed R4’s pressure wound to stage 3 on 6/7/23. Based on review of R4’s ADL notes, facility staff performed bed mobility for R4 daily; however, there is no specific documentation regarding the care and monitoring of R4’s pressure wound. During an interview with S1, LPAs requested additional evidence (including documentation) that address wound care, monitoring and progress of R4; however, S1 indicated that S1 does not have evidence to provide.

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 $1000 is issued in addition to citation due to injury related to violation of Section 1569.312(e) due to repeat violation. 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 with administrator Caleb Summerhays, and a copy of this report and the 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
HSC
1569.312(e)
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1569.312 Basic services requirement. Every facility...shall provide at least the following basic services: (e) Monitoring...residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
This was not met as evidenced by:
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Licensee to submit a plan in place to ensure residents are being checked regularly. Plan to be submitted to the Department by the POC due date.
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Based on interviews and record reviews, the licensee did not ensure to provide adequately, and timely care and monitoring of R4’s pressure wound while in care at the facility, which resulted in the escalation of R4’s pressure wound to stage 3. This poses an immediate health and safety risks to persons in care.
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Licensee 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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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
LIC9099 (FAS) - (06/04)
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