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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 09/17/2024
Date Signed: 09/17/2024 03:22:58 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
07/26/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240726162242
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: 119DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
03:38 PM
ALLEGATION(S):
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Staff did not assist resident with obtaining medical care.
Staff are not addressing a scabies outbreak.
INVESTIGATION FINDINGS:
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On 09/17/2024 at 2:30 PM, 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 Dearing 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 119. A brief interview was conducted with administrator.
Allegation: Staff did not assist resident with obtaining medical care.

It was alleged that staff did not assist resident with obtaining medical care. This investigation consisted of records reviewed, interviews with staff and residents. Based on resident 1 (R1)’s Individual Service Plan (ISP) dated on 04/10/2024, resident refuses care often, and caregiver have to reapproach (R1) throughout the day base on his/her mood. Moreover (R1)’s ISP does not indicate that (R1) has any on going issue with maggots oh his or her feet or any open sores. (R1)’s ISP also stated that (R1) refuses showers and only want bed bath and that care staff is able to transfer (R1) to the shower chair; however, (R1) refuses and that care staff does their best when doing bed baths.
Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20240726162242
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: 09/17/2024
NARRATIVE
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(R1)’s LIC 602 Physician’s report dated on 03/05/2024 indicated that (R1) has a history of skin condition/breakdown. Based on (R1)’s Home Health Care Notes, it was learned that (R1) had home health services on 11/02/2023 for venous stasis ulcer. Records also indicated that (R1) was being seen by a nurse from 08/01/2023 to 11/29/2023 for wound care twice a week. (R1) was discharge from home health on 12/06/2023 since (R1) did not have any more skin issues. On 02/09/2024, (R1) resident was opened to nursing services for wound on buttocks with stage 2. On 02/20/2024 (R1) as was closed to home health services as it the wound was healed and that there is no open area or any wounds. LPA Lee also interviewed out of 7out of 7 residents who have no concern with staff not assisting resident with obtaining medical care. Moreover, (R1) denied the allegation and has no concern that staff are not obtaining medical care to (R1). LPA Lee also interviewed 5 out of 5 facility staff who denied the allegations.

Allegation: Staff are not addressing a scabies outbreak.

It was alleged that Staff are not addressing a scabies outbreak. This investigation consisted of records reviewed, interviews with staff and residents in care. Based on records reviewed (R2) has eczema and sent out to the hospital on 06/14/2024 due (R2) being itchiness and was prescribed Triamcinolone Acetonide. It was also learned that (R3) was seen on 05/10/2024 by a Dermatology Clinic for a widespread eczema like rash and was prescribed Triameinolone ointment. LPA Lee also interviewed 7out of 7 residents who have no concern with staff not addressing a scabies outbreak. Moreover, (R1) denied the allegation and has no concern. LPA Lee also interviewed 5 out of 5 facility staff who denied the allegation. 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.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited.


A copy of this report was provided, along with Appeal Rights and the LIC 811, the Confidential Names List.
Exit interview.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/26/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240726162242

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: 119DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
03:38 PM
ALLEGATION(S):
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9
Staff did not ensure resident’s assistive equipment needs were met.
INVESTIGATION FINDINGS:
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On 09/17/2024 at 2:30 PM, 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 Dearing 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 119. A brief interview was conducted with administrator.

Allegation: Staff did not ensure resident’s assistive equipment needs were met.
It was alleged that staff did not ensure resident’s assistive equipment needs were met. This investigation consisted of records review and observation. Based on (R1)’s Individual Service Plan (ISP) dated on 04/10/2024, residents use the following assistive devices: wheelchair and medical bed. On 07/29/2024 LPA Lee observed resident room #303, (R1)’s transfer pole not in good repair. It was learned that resident 1 (R1)’s transfer pole does not lock in place which makes it hard for the (R1) to pull himself/herself up from bed. It was also learned that (R1)’s wheelchair is also not in good repair and that (R1) is using another resident’s wheelchair that is also not in good repair.
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240726162242
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: 09/17/2024
NARRATIVE
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 It was learned that (R1) had the wheelchair zip tie to keep the arm rest from folding up. Furthermore, (R1)’s medical bed does not crank up to a standing position for caregivers to give (R1) a bed bath.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240726162242
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: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2024
Section Cited
CCR
87307(d)(2)
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87307(d)(2) Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement was not met as evidence by:
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During 07/29/24 facility visit, the maintenance staff was able to fix (R1)’s transfer pole and have requested for a new wheelchair for (R1). (R1)’s bed will also be replaced. During today’s visit. LPA Lee observed (R1) had a new bed and wheelchair. POC will be cleared today’s visit.
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Based on records review and observation the facility staff did not ensure that (R1) assistive equipment needs are in good repair. This posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5