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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 05/07/2024
Date Signed: 06/26/2024 10:41:08 AM

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
02/23/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240223095550
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:
05/07/2024
UNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Caleb Sumerhays and Mel DearingTIME COMPLETED:
12:16 PM
ALLEGATION(S):
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Staff did not ensure resident’s assertive device was accessible.
Staff did not communicate with resident's authorized representative.
Resident's call button was in disrepair.
INVESTIGATION FINDINGS:
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On 05/07/2024 at 8:25 AM, 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 finding for the allegation above. The current census is 113. A brief interview with conducted with Nurse Mel.

Allegation: Staff did not ensure resident’s assertive device was accessible
It was alleged staff did not ensure resident’s assertive device was accessible. This investigation consisted of interviews with staff and resident responsible party, records reviewed and observations. LPA Lee interview 4 facility staff who denies the allegation stating that (R1) does not like to use (R1)’s walker and puts the walker in (R1)’s closet. On 03/04/2024 and 03/14/2024, LPA Lee attempted to interview (R1) who denies being interviewed.

Continued LIC 9099-C

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

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
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-20240223095550
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: 05/07/2024
NARRATIVE
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 On 03/04/2024 at 8:55 AM LPA Lee observed resident 1 (R1) bedroom # 213. In (R1)’s bedroom, LPA Lee observed two signs above resident's bed. The first sign states, " PLEASE PLACE WALKER IN FRONT OF RESIDENT AT ALL TIMES." The second sign states, "DO NOT REMOVE WALKER FROM BEDSIDE." LPA Lee observed (R1) wheelchair was placed next to (R1)’s bed to the right of (R1) and (R1)’s walker was placed by the foot of (R1) bed.

On 03/14/2024 at 11:32 AM, LPA Lee also observed (R1)’s walker next to (R1)’s bed. On 04/4/2024 at 8:34 AM, LPA Lee visit the facility to follow-up on a different complaint and LPA Lee observed (R1)’s walker and wheelchair are next to (R1)’s bed. During today’s visit 05/07/2024 at 2:44 PM, LPA Lee observed (R1) lying in bed with a sheet covered (R1)’s face. LPA Lee observed (R1)’s wheelchair next to (R1)’s bed and the walker was next to (R1)’s bed as well. Based on (R1)’s Individual Service plan assisted Living Wavier it indicates to ensure walker and or wheelchair is within reach at all times.

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.



Allegation: Staff did not communicate with resident's authorized representative

It was alleged staff did not communicate with resident's authorized representative. This investigation consisted of interviews with staff and resident responsible party and records reviewed. Four facility staff denies the allegations. LPA Lee reviewed email records and it was learned that on 11/06/2023 at 12:16 PM, Resident Care Director, Ashana Pillay sent an email regarding (R1)’s doctor’s order to (R1)’s responsible party. On 11/28/2023 at 12:25 PM, Ashana also emailed (R1)’s responsible party regarding (R1)’s medication hold. On 12/04/2023 at 8:37 AM, another email from Ashana to (R1)’s responsible party regarding (R1)’s dental work and Pradaxa medication. On 12/05/2023 at 9:40 AM, another emailed was sent to (R1)’s responsible party from Ashana regarding (R1)’s dental work and Pradaxa medication. On 12/05/2024 at 9:40 AM, another email sent to (R1)’s responsible party to follow-up on (R1)’s dental work and Pradaxa medication from Ashana. On 01/17/2024 at 12:31 PM, an email was sent to (R1)’s responsible party regarding (R1)’s charger.

Continued LIC 9099-C

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

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240223095550
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: 05/07/2024
NARRATIVE
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 On 01/17/2024 at 1:28 PM, another email from Ashana to (R1)’s responsible party to follow-up on (R1)’s charger. On 01/18/2024 at 9:44 AM, an email was sent to (R1)’s responsible party from Ashana regarding (R1)’s care conference notes. . On 12/05/2023 at 6:22 AM, an email was sent to (R1)’s responsible party from administrator Caleb Summerhays regarding (R1)’s dental work and Pradaxa medication. On 01/16/2024 at 8:07 AM, an email was sent from Caleb to (R1)’s responsible party regarding (R1)’s care conference notes.

On 01/24/2024 at 8:15 AM, an email was sent out to (R1)’s responsible party from Caleb regrading responsible party’s concerns. On 01/25/2024 at 1:06 PM, an email was sent from Caleb to (R1)’s responsible party regarding (R1)’s care conference notes. On 01/27/2024 at 7:43 AM, an email was sent out to (R1)’s responsible party regarding (R1)’s walker not in place. On 01/31/2024 at 12:16 PM, an email was sent out to (R1)’s responsible part from Nurse Mellina Dearing regarding (R1)’s medicine changes and concerns.

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.



Allegation: Resident's call button was in disrepair.

It was alleged resident's call button was in disrepair. This investigation consisted of record reviews, observations and interviews with staff and resident. On 03/04/2024 At 8:55 AM, LPA Lee checked 9 resident call lights and 9 out of 9 call lights were in good repair. During 03/14/2024 visit, LPA Lee also tested 7 resident’s call string. It was learned that 7 of those call strings are in good repair. It was learned that when LPA Lee pulled the residents call string, the residents light outside of the residents’ room would turn on. Moreover, it was learned that once the residents’ lights outside of resident room are turned on it will then trigger to the call panel in the front lobby and to the nurse station. Four facility staff denies the allegations. LPA Lee interviewed 9 residents and 5 out of 9 residents denies that the call button is in disrepair. LPA Lee also asked to review call log records and it was informed to LPA Lee that the facility does not have call logs and that they only have call lights that will trigger outside of residents’ room and to the nurse station and to the front lobby.

Continued LIC 9099-C

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

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240223095550
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: 05/07/2024
NARRATIVE
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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, Title 22, Division 6, Chapter 8, no deficiencies observed. An exit interview was held, and a copy of the report was provided.


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

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240223095550
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: 05/07/2024
NARRATIVE
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SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5