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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 02/23/2024
Date Signed: 02/23/2024 03:10:48 PM


Document Has Been Signed on 02/23/2024 03:10 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 LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:CALEB SUMMERHAYSFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 111DATE:
02/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH: Caleb Summerhays and Mel DearingTIME COMPLETED:
11:31 AM
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit to follow up on two incident reports. LPA met with administrator Caleb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The current census is 111.

The Department received an LIC 624 Unusual Incident Report on 12/31/2023 at 3:37 PM, regarding an incident that occurred on 12/27/2023. Resident 1 (R1) was found choking on a watermelon. Med-tech tried to do the Heimlich maneuver but was unsuccessful and alpha one was called, and resident was transported to Methodist. LPA Lee reviewed (R1)’s LIC 602 Physician’s Report. Based on records reviewed, (R1) is not on any special diet and (R1) is able to feed self. During today’s visit LPA Lee interviewed (R1) who stated that (R1) did not chew the watermelon before swallowing and that the watermelon went down the wrong pipe. (R1) also confirms that it was an accident and that (R1) will before be swallowing. Based on an interview with Nurse Mel the facility will ensure to remind (R1) to chew (R1)’s food and eat slowly. It was also learned that (R1) does not have a change in eating habit and reassessment was completed verbally with (R1) and it was documented.

The Department received an LIC 624 Unusual Incident Report on 02/19/2024 at 10:50 AM regarding an
incident that occurred on 02/09/2024. Resident 2 (R2) accused Staff 1 (S1) of stepping on (R2)’s ankle. During the interview with (R2) and facility staff it was learned that statements from (R2) and staff are inconsistent; therefore, it is unclear exactly what happened. During the interview with (R2), (R2) stated that (R2) doesn’t remember who stepped on (R2)’s ankle. In addition (R2) also stated that (R2) doesn’t remember how the incident happened. LPA Lee asked (R2) if LPA Lee can look at (R2)’s left ankle and (R2) gave

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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: 02/23/2024
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LPA Lee consent. LPA Lee observed (R2) having an ankle dressing on (R2)’s left ankle. LPA Lee interviewed (S1) and (S1) denies the allegation. LPA Lee also interviewed (S2) who (R2) reported the incident. (S2) stated that (R2) informed (S2) that (R2) hurt (R2)’s ankle as (S1) helped (R2) to transfer from bed to wheelchair. (S2) stated that (R2) didn’t indicate how (R2) hurt (R2)’s ankle. On 02/09/2024 (R2) was sent out to Methodist Hospital for evaluation. LPA Lee reviewed (R2) discharge document on 02/09/2024 and the reason for the visit was not documented and discharge diagnosis was also not documented.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was given to the facility.


SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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