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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 10/22/2021
Date Signed: 10/22/2021 01:08:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CITY CREEK ASSISTED LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:LITTERER, KEVINFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 599-7033
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 106DATE:
10/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Steve BaddleyTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived at the facility unannounced to conduct a Health & Safety Case Management Visit. LPA Valerio and LPM Richardson were screened for COVID-19 symptoms prior to being allowed entry into the facility.

LPA and LPM asked when Administrator Kevin will be arriving to the facility. LPA and LPM learned that Administrator Kevin resigned and his last day was on 10/15/2021. Community Care Licensing was not informed of the Administrator leaving nor was an updated LIC 308 submitted. LPA and LPM was later met with Kalesta Regional Director of Operations Steve Baddly. Regional Director stated the Licensee has a new leadership team starting on 10/25/2021. LPA and LPM discussed LIC 808 mitigation plan, current open complaints, and status of facility with Regional Director.

LPA and LPM toured the facility inside and out to ensure compliance with Title 22 Regulations. Facility was in good repair. Hand sanitizers were located in each hall way.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during this visit and can be found on LIC 809-D. An exit interview was held, and a copy of the report was given Regional Director
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CITY CREEK ASSISTED LIVING
FACILITY NUMBER: 342700835
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited

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87045 (a) Administrator - Qualification and Duties All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute...This requirement was not met as evidenced by:
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Based on observations and interviews, the licensee did not inform the resignation of Administrator Kevin and did not send an updated LIC 308, which poses an immediate health and safety risk to residents in care.
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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) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
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