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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 11/01/2023
Date Signed: 12/22/2023 08:48:00 AM


Document Has Been Signed on 12/22/2023 08:48 AM - 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 LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:CALEB SUMMERHAYSFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 108DATE:
11/01/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
02:45 PM
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A Non-Compliance Conference (NCC) was conducted on this day, 11/01/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 10/13/2023. Due to facility staff availability the NCC meeting was rescheduled for today. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Stephen Richardson, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Jamie Ivey Canady, LPA Pang Lee, facility board member Ryan Williams, facility board member Scott Clawson, Director of Nursing Melina Dearing, Adminstrator Caleb Summerhays and AShawna Pillay, Resident Care Director. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well.

Since the facility has been re-licensed in 2021, there have been 16 Type A citations and 8 Type B citations.

The focus of the concerns at this time were as followed:

- Multiple medication violations including Insulin not being provided by a skilled professional
- Care and Compliance
- Facility resident pressure injuries
- Update of Facility staff roles, duties, and responsibilities

Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
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: 11/01/2023
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- Pharmacy addition for filling resident prescriptions
- Onboard of Clinical Consultant
- Wanderguard System

Licensee agreed to do the following in order to bring the facility into compliance: Please provide the following to LPA by 11/7/23.

- Provide the Department with an updated LIC500
- Licensee shall provide updated Plan of Operation that includes new staff department head personnel roles, responsibilities and duty statement
- Licensee shall provide the Department with a plan of how the facility will assess and monitor resident skin issues.
- Licensee shall create a plan and policy on residents with dementia
- Licensee will provide the Department a plan for proof of staff, staff training and monitoring required staff training to include updated staff training documents for CPR/First Aid of facility staff
- Licensee shall provide the Department with proof of staff certified to assist residents with insulin and a plan regarding how the facility handles insulin assistance when certified staff is not on site.

Licensee has accepted the offer of Technical Support Program (TSP) offered by the Department

Exit Interview

Licensee/Administrator signature on file.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC809 (FAS) - (06/04)
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