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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 05/14/2024
Date Signed: 05/14/2024 03:43:29 PM


Document Has Been Signed on 05/14/2024 03:43 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: 113DATE:
05/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 AM
MET WITH:Caleb Summerhays and Mel DearingTIME COMPLETED:
03:50 PM
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On 05/14/2024, Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to
conduct a case management visit. LPA met with administer Caleb Summerhays and Nurse Mel Dearing and explained the purpose of the visit. The census is 113 with 6 Resident Aid, 1 Resident Aid Lead, 3 Med-techs, 1 Residential Habilatation and 10 supervisors.

The purpose of this case management is due to following up on some concerns during complaint investigation control number 27-AS-20240223095550. LPA Lee reviewed resident 1 (R1)’s file. Based on records review (R1)’s LIC 602 Physician Report dated on 07/26/2023, (R1) is diagnosed having dementia. During complaint investigation on 03/04/2024, LPA Lee was given (R1)’s Individual Service Plan Assisted Living Waiver (ISP) that was dated on 03/02/2023. During today’s visit it was learned that (R1) does have a current (ISP) dated on 03/19/2024 and that the facility didn’t ensure that LPA Lee received (R1)’s current (ISP). It was also learned that (R1) has (ISP) completed every six months with nurse Steven Heppell from Elder Options and (R1)’s (ISP) is reviewed with City Creek Nurse Mel Dearing and (R1)’s responsible party.

Based on records review (R1)’s Kaiser notes dated on 10/28/2023, (R1) has history of falls and that (R1)’s last hospitalization was from 10/27/2023 to 10/30/2023 due to falls and orthostatic hypotension, as a result Lasix, Aldactone and lisinopril were held. (R1) also had two unwitnessed falls on 01/26/2024 and was admitted to Kaiser South and discharged on 01/29/2024. Moreover, on 04/13/2024, (R1) also had multiple falls within 24 hours and was transported to Kaiser via paramedics. (R1) then was discharged on 04/17/2024 and was evaluated for seizure, head injury. Per LIC 624 dated on 04/18/2024, City Creek stated that (R1) will be monitor and on alert charting conduct for 72 hours. Based records review, (R1) was on alert charting for 72 hours with progress notes dated on 04/18/2024, 04/19/2024, 04/20/2024, 04/21/2024 and 04/22/2024, 04/23/2024 and 04/24/2024. Based on records review (R1) was assessed for Fall risk using “Morse Fall Scale” on 10/30/2023 and is considered a high-risk fall resident. It was also learned that a fall prevention plan was put in placed for (R1).
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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
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: 05/14/2024
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 On 04/15/2024 another fall risk using “Mores Fall Scale” was conducted as well. On 04/02/2024, (R1) was evaluated for physical therapy; however, it was noted on outside agency assessment form that (R1) is not willing to participate and corporate in physical therapy.

Based on (R1) After Summary Kaiser discharge notes on 01/29/2024 it indicated that (R1) was treated in the hospital for severe sepsis due to community acquired pneumonia, orthostatic hypotension. LPA Lee asked Nurse Mel if there was any other resident during January that also was treated for pneumonia as well. Nurse Mel stated that no other residents was treated for pneumonia during that time frame. Based on City Creek records review regarding LIC 624 incident report during the month of January there was no indications that there were other residents admitted to the hospital due to pneumonia.

No citations were cited during today’s visit. An exit interview was conducted with Nurse Mel Dearing and a copy of this report was given to Nurse Mel Dearing.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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