342700835-3-14-2024-27-AS-KHOS-D3HN8M-20240319101434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:32:44 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
12/22/2023 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: 110	DATE:	03/14/2024
		UNANNOUNCED	TIME BEGAN:	11:21 AM
MET WITH:	Katelyn Becker and Ashana Pillay		TIME COMPLETED:	12:24 PM

ALLEGATION(S):

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Staff did not ensure that resident received medical attention while in care.

INVESTIGATION FINDINGS:

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On 03/14/2024 at 11:21 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with Health Services Supervisor Katelyn Becker and Resident Care Director Aasahana Pillay and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 110. A brief interview was conducted with Katelyn and Asahana.

Allegation: Staff did not ensure that resident received medical attention while in care.
It was alleged that staff did not ensure that resident received medical attention while in care. This investigation consisted of records reviewed, interviews with staff, residents, a VA Doctor at VA Martinez, and a Rehab Specialist at VA Martinez. LPA Lee interviewed 10 residents and 9 out of 10 residents have no concerns with staff not ensuring that resident receives medical attention while in care. Four facility staff denied the allegations. Throughout the investigation, it was learned that resident 1 (R1) was not receiving (R1) Ophthalmologist appointments.
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: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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: 03/14/2024

NARRATIVE

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The investigation revealed that (R1)’s Primary Care Provider (PCP) comes to the facility once a week for (R1)’s primary visits and to refill (R1)’s medications. On 05/02/2023 (R1)’s PCP informed the facility that (R1) needed to be referred to an Ophthalmologist for (R1) Glaucoma. It was also learned that (R1) can only be referred to a VA Ophthalmologist; therefore, (R1) had to be reestablish with a VA PCP to get referred to a VA Ophthalmologist. Based on records review, on 07/12/2023, the facility was able to establish a VA PCP for (R1). In addition, (R1) was also referred to a VA Ophthalmologist and had an appointment on 09/21/2023, per (R1)’s prior PCP recommendation. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Lee was unable to corroborate the allegations.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation regarding staff did not ensure that residents received medical attention while in care is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this 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: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

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