342700835-2-1-2024-27-AS-KHOS-D26TF4-20240205134054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 02/01/2024
Date Signed: 02/01/2024 03:34:22 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
01/31/2024 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240131084542

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: 110	DATE:	02/01/2024
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Mel Dearing and Joseph Simon		TIME COMPLETED:	03:46 PM

ALLEGATION(S):

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Facility did not obtain a building permit prior to alterations to the building.

INVESTIGATION FINDINGS:

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On 02/01/2024 at 11:55 AM, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced facility visit to open a complaint investigation and delivered the finding. LPA Lee met with Nurse Mel Dearing and Maintenance Director Joseph Simon and explained the purpose of today's visit. The census is 110.

Allegation: Facility did not obtain a building permit prior to alterations to the building.
It was alleged that the facility did not obtain a building permit prior to alterations to the building. This investigation consisted of records reviewed, interviews with staffs and observations. Throughout the course of the investigation, it was learned that the facility took down a Sophet wall and a receptionist desk on 06/22/2023 and then on 06/29/2023 the facility added a structured wall to the area and did not obtain proper permits. During a fire inspection follow-up in July 2023 the facility was given directions to submit permits and plans to Sacramento County Building Department and Metro Fire to address the added structure wall.

Continued LIC 9009-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240131084542

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: 02/01/2024

NARRATIVE

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During today’s visit, it was learned that the facility attempted to obtain permits after; however, the facility did not want to pay the fees associated with the permit. In September of 2023 the facility decided to resort to taking down the additional structure wall. A review of their facility sketch confirms that this additional structure was not approved during licensure.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Mel Dearing and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20240131084542

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: 02/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/09/2024 Section Cited CCR 87305(a)	1 2 3 4 5 6 7	87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to read regulation 87305(a) and submit a signed written declaration of understanding via email to LPA Lee (pang.lee@dss.ca.gov) stating that a building permit will be obtained prior to construction or alternations at the facility.
	8 9 10 11 12 13 14	Based on LPA's observation, records review and interviews the licensee did not comply with the section cited above. The facility did not obtain a building permit prior to alterations to the building by removing a sophet wall and receptionist desk and adding a structured wall and then later removed the structure wall, which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC9099 (FAS) - (06/04)

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