342700835-12-1-2023-27-AS-PLEE-CY4VM7-20231201153300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 12/01/2023
Date Signed: 12/01/2023 03:33:11 PM

Document Has Been Signed on 12/01/2023 03:33 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 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:	DATE:	12/01/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Aashana Pillay, Mel Dearing and Caleb Summerhays		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/01/2023 at 8:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to the facility to conduct a case management visit in relation to 6 incident reports received. LPA met with Resident Care Director, Aashana Pillay and explained the purpose of the visit. LPA was later met by Administrator, Caleb Summerhays and Licensed Vocational Nurse (LVN), Mel Dearing. The 10/24/2023 at 2:15 PM, the department received an incident report that occurred on 10/16/2023 with resident 1 (R1). R1’s blood sugar was low, and resident was unresponsive. Resident was transported to Methodist Hospital via paramedics. LPA Lee interviewed (R1) who stated that (R1) blood sugar is being checked by staff 4 times a day between every meal and bedtime. (R1) stated that (R1) has no concerns. It was learned that (R1) is on a sliding scale for insulin injections. It was learned that Med-tech goes around and do their med pass and assist R1 with (R1) glucose check. (R1) does own glucose check and the med-tech will let (R1) know what (R1) glucose reading is and confirms it with (R1) with the insulin units that is needed for (R1). LPA Lee reviewed (R1) UIR, Physician Report, Individual Service Plan, Progress Notes and Discharge/Follow-up Instructions. Based on records reviewed, (R1) is recommended to have a follow-up with primary care provider within 2 to 4 days. It was learned that (R1) had an appointment on 11/01/2023 to follow up on (R1). It was also learned that the facility had all the documentation for (R1) in file. On 11/13/2023 at 9:30 AM, the department received an Incident Report. Incident occurred on 11/04/2023 with (R2). Per incident report, (R2) had an unwitnessed fall and was found lying on the floor supine position head between a rocking chair in another resident room around 1549 with a tear on left elbow. (R2) stated that she did not hit her head. (R2) was transported to Sutter General Hospital for further assessment. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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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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
	VISIT DATE: 12/01/2023

NARRATIVE

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LPA Lee interview with facility LVN, Mel Dearing, it was learned that (R2) is on a contract with Sutter Pace Program that does not offer hospice services to their resident and Sutter Pace Program only offers comfort care. The facility does not accept residents with “comfort care” and only resident with “hospice” services; therefore, (R2) is no longer residing at the facility. It was learned that (R2) needed a higher level of care and is transferred to a skill nursing facility, Saylor Ln Health Care. LPA Lee reviewed (R2) UIR, Physician Report, Individual Service Plan, Progress Notes. Based on interviews and records reviewed it was learned that (R2) was placed on fall monitoring and the facility implemented closer supervision of resident. A “Morse Fall Scale” was conducted with (R2). Per (R2) after summary there was no follow-up needed.

On 11/13/2023 at 9:28 AM, the department received an UIR. Incident occurred on 11/05/2023. (R3) had a fall and was found on the floor laying on her back in the hallway around 1433. (R3) was transported to Kaiser South Hospital for further assessment. LPA Lee reviewed (R3) UIR, Physician Report, Individual Service Plan, Progress Notes. Based on interviews and records reviewed it was learned that (R3) was placed on fall monitoring and the facility implemented “Morse Fall Scale” with (R3). It was also learned that (R3) has an appointment scheduled with (R3) PCP for 12/5/2023 to follow-up on 11/05/2023 Kaiser Permanete after summary discharge. It was also learned that (R3) LIC 625 Appraisal/Needs and Service Plan was updated after (R3) was discharged on 11/05/2023.

(R4) had two unwitnessed falls. On 11/06/2023 at 4:29 PM and 11/13/2023 at 9:34 AM, the department received two unusual incident reports. The first Incident occurred on 10/30/2023. (R4) had an unwitnessed fall at 0020 in (R4) room. (R4) stated that (R4) was trying to transfer from bed to wheelchair and hit (R4) head on the nightstand. The second incident, (R4) had an unwitnessed fall and was found by laying on the floor in a supine position in (R4) room. Resident stated (R4) hit (R4) head. On both occasion (R4) was transported to Mercy General Hospital for further assessment. LPA Lee reviewed (R4) UIR, Physician Report, Individual Service Plan, Progress Notes. Based on interviews and records reviewed (R4) was placed on fall monitoring and the facility has implemented “Morse Fall Scale” with resident. Per discharge notes it is recommended that (R4) has a follow-up appointment with (R4) PCP. It learned that (R4) was seen by Dr. Patrick on 11/08/2023 at 9:45 AM per follow-up directions from discharge notes.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 12/01/2023

NARRATIVE

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On 11/15/2023 at 9:30 AM, the department received an unusual incident report. Per incident report, incident occurred on 11/12/2023 around 1230 med tech was called to (R5) due to (R5) being short of breath, med tech attempted Heimlich Maneuver. Later resident showed signs of shortness of breath and another Heimlich Maneuver was attempted. There were no signs of dislodging in (R5) throat; however, (R5) was heavily drooling. LPA Lee interviewed (R5) who stated that (R5) has no concerns and is aware that (R5) can only eat soft food. (R5) stated “soft food only.” LPA Lee reviewed (R5) UIR, Physician Report, Individual Service Plan, Progress Notes. Based on interview and records reviewed (R5) is on mechanical soft and honey thicken liquid. (R5) had a follow-up appointment on 11/17/2023.

Facility had fall prevention plan in place. Per California Code of Regulations (CCR) - Title 22 - no deficiencies were observed. An exit interview was held, and a copy of the report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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