342700835-2-8-2024-27-AS-KHOS-D3HN8N-20240319101435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 02/08/2024
Date Signed: 02/08/2024 03:02:57 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
12/22/2023 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231222104828

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: 93	DATE:	02/08/2024
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Aashana Pillay and Mel Dearing		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not ensure that resident received their medication(s) as needed.

INVESTIGATION FINDINGS:

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On 02/08/2024 at 12:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Resident care director Aashana Pillay and Nurse Mel Dearing and explained the purpose of the visit. The purpose of this visit is to deliver a complaint finding for the allegation above. The current census is 93. A brief interview with conducted with Mel.

Allegation: Staff did not ensure that residents received their medication(s) as needed.
It was alleged that staff did not ensure that residents received their medication(s) as needed. This investigation consisted of records reviewed, interviews with staff, residents, and outside agency. LPA Lee interviewed 4 out 4 facility staff who denied the allegations. Nurse, Mel Dearing stated that her staff are administering residents’ medications; however, the staff lacks documenting that residents’ medications has been administered to resident; therefore, it is unclear if resident’s medications were being administer to residents. LPA Lee also interviewed 9 out 9 residents and 6 out of 9 residents stated that they are not getting their medications from facility staff.
Continued LIC 9099-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: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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-20231222104828

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: 02/08/2024

NARRATIVE

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Furthermore, based on resident 1 (R1) Quick MAR records for the month of March 2023, it was learned that 12 out of 14 medications were not marked as being administered to (R1). For the month of September 2023, it was learned that 12 out of 16 medications were not marked as being administered to (R1). For the month of October 2023, it was learned that 14 out of 14 medications were not marked as being administered to (R1). For the month of November 2023, it was learned that 15 out of 15 medications were not marked as being administered to (R1). (R1) medications for Brimonidine Tartrate 0.2% Solution and Dorzolamide HCL-Timolol MAL 22.3-6.8 solution were not marked as being administered to (R1) for the month of March, September, October, and November.

Based on records review, and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, citations for deficiencies can be found on the LIC 9099 -D. Failure to correct deficiencies may result in additional civil penalties. Appeal Rights provided. An exit interview was held, and a copy of the report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231222104828

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: 02/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/23/2024 Section Cited CCR 87465(6)	1 2 3 4 5 6 7	87465(6) Incidental Medical and Dental Care The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator will ensure that all facility staff who handle medications are re-trained in administering and documenting medications when given to residents in care.
	8 9 10 11 12 13 14	Based on observation, interviews and record review, the licensee did not comply with the section cited above. Facility staff did not ensure MARs were being maintained for R1. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Administrator will send LPA Lee copies of staff training sign in sheets with facility staff signatures and the materials used for the training. POC will be emailed to LPA Lee by POC date 02/23/2024 by 5:00 PM end of day.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

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