342700835-2-12-2024-27-AS-KHOS-D2LPPU-20240219103008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 02/12/2024
Date Signed: 02/12/2024 03:10:45 PM

Unsubstantiated

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
12/26/2023 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231226112314

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:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Caleb Summerhays and Mel Dearing		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

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Staff pushed resident which resulted in a fall.
Staff did not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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On 02/12/2024 at 8:30AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Administrator Caleb Summerhays and Nurse Mel Dearings and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 110. A brief interview was conducted with both Celeb and Mel.

Allegation: Staff pushed resident which resulted in a fall.
It was alleged that staff pushed resident which resulted in a fall. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. LPA Lee interviewed 9 out of 9 resident and 8 of those 9 residents stated they have not experienced and witnessed any facility staff pushing residents which resulted in a fall. LPA Lee also interviewed 5 out of 5 facility staff who denies pushing and witnessing any facility staff pushing resident which resulted in a fall. LPA Lee called the number provided by the complainant for additional details to assist in this investigation, and no further information could be obtained.
Continued LIC 9099-C

Unsubstantiated

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: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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-20231226112314

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: 02/12/2024

NARRATIVE

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In addition, LPA Lee was not able to confirm with resident 1 (R1) about the incident on 12/25/2023. Based on the information gathered, it is unclear that staff pushed resident which resulted in a fall. Therefore, the allegations cannot be corroborated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

Allegation: Staff did not treat resident with dignity and respect.

It was alleged that staff did not treat resident with dignity and respect. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. LPA Lee interviewed 9 out of 9 residents and 7 out of those 9 resident stated they have not experienced and witnessed facility staff not treating residents with dignity and respect. LPA Lee also interviewed 5 out of 5 facility staff who denies that facility staff doesn’t treat residents with dignity and respect. In addition, LPA Lee called the number provided by the complainant for additional details to assist in this investigation, and no further information could be obtained. LPA Lee was not able to confirm with resident 1 (R1) about the incident on 12/25/2023. Based on the information gathered, it is unclear that staff did not treat resident with dignity and respect. Therefore, the allegations cannot be corroborated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

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