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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:08:26 PM

Unfounded


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
05/22/2023 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20230522082455
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
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Resident was physically assaulted by another resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Caleb Summerhays.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with residents, interviews with staff, and review of facility resident and medical files.

The Department has determined the following as it relates to the allegations: Resident was physically assaulted by another resident while in care.

Continued on LIC 9099 - C...
Page 1 of 2
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20230522082455
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: 10/26/2023
NARRATIVE
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On 9/25/2023 LPA Ivey Canady requested, received and reviewed facility and resident files regarding current allegations. Based on review of R1 facility and medical files, R1 has been diagnosed with cognitive decline. According to interviews with R1 and facility staff, R1 is not clear on claimed occurrences. During staff interviews and facility file review, it was learned that R1 displays behaviors associated with diagnosis as described in facility medical file. In accordance with facility appraisal needs and service plan, facility is providing R1 with agreed upon and planned services. Based on review of facility service plan and staff notes, facility is also proactively providing R1 staff implementations of the objective plan listed on the needs and service plan. According to interview with R1, there was no actual physical attack that occurred with R2. Based on interviews with residents and staff, there is no evidence of physical interaction of any kind between R1 and R2. Therefore the allegation Resident was physically assaulted by another resident while in care is Unfounded.
Due to the information gathered LPA finds the allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.  Exit interview was held and a copy of report and appeal rights were 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
05/22/2023 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20230522082455

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
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff member is financially abusing resident while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Caleb Summerhays.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with residents, interviews with staff, review of facility transaction files and resident files.

The Department has determined the following as it relates to the allegations: Staff member is financially abusing resident while in care.

Continued on LIC 9099 - C...
Page 1 of 2
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20230522082455
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: 10/26/2023
NARRATIVE
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On 10/24/2023 LPA Ivey Canady requested and received facility Surety Bond, facility resident files, and facility resident fund transaction files for review. According to Surety Bond received by the facility on 10/1/2019, facility is covered for transactions for residents up to the amount of $500 for all residents. According to facility transaction records, receipts, resident interviews and staff interviews, facility assisted R1 and R2 with the purchase of personal essentials with the total amounts not exceeding $42 per transaction per month. Regarding facility file review, R1 Individual Service Plan and facility Pre-placement appraisal, R1 has been diagnosed with cognitive impairment and dementia. According to facility Pre-Placement Appraisal for R1, R1 is a smoker and is listed as smoking 3 times per day. Based on facility transaction receipts, facility staff provides a monthly service of purchasing cigarettes for and personal items for R1 and R2. According to bank transaction receipts dated 06/23/2023 and 08/29/2023, and facility staff interviews dated 10/11/2023, facility staff provides R1 and R2 transportation to a banking institution for the purpose of withdrawing funds to use for the purchase of cigarettes and other personal items. Based on facility transaction receipt review and facility transaction log receipt review, R1 and R2 funds withdrawn in reviewed transactions are used for the purpose of purchasing cigarettes and personal items for R1 and R2. Therefore the allegation -Staff member is financially abusing resident while in care is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is 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 and appeal rights were 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4