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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 05/15/2024
Date Signed: 05/15/2024 11:54:02 AM

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
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:
05/15/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Caleb Summerhays and Mel DearingTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not provide incident reports to resident’s authorized representative.
Staff did not dispense medication as prescribed.
INVESTIGATION FINDINGS:
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On 05/14/2024 at 11:30 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 provide incident reports to resident’s authorized representative
It was alleged that staff did not provide incident reports to resident’s authorized representative. This investigation consisted of interviews with staff and resident responsible party and records reviewed. LPA Lee interview 4 facility staff who denies the allegation stating that resident (R1) did have a fall but that (R1) didn’t sustain any injuries. LPA Lee attempted to interview (R1) on 03/04/2024 and 03/14/2024, who refused to be interviewed.

Continued LIC 9099-C
Substantiated
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: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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: 05/15/2024
NARRATIVE
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 Based on interview with Resident Care Director, Aashana Pillay admitted that (R1) had two falls and was admitted to the hospital in January and that a phone call was made to (R1)’s responsible party; however, a written report was not provided to (R1)’s responsible party. Based on record review it was noted that (R1) is a high-risk fall resident. It was learned that on 01/26/2024, (R1) had two un-witnessed falls. During the second fall on 01/26/2024, (R1) was admitted to Kaiser. Based on records it was noted on (R1)’s chart that (R1) was admitted to Emergency Department (ED) on 1/26/2024 after a fall with possible syncope, diagnosed with severe sepsis from possible community pneumonia. LPA Lee also reviewed (R1)’s After Visit Summary from Kaiser Permanente visit from 01/27/2024 to 01/29/2024 which states that “you were treated in the hospital for severe sepsis due to community acquired pneumonia, orthostatic hypotension.” Moreover, on (R1)’s progress notes from City Creek it was documented on 01/27/2024, that resident was admitted to Kaiser south for further evaluation and infection. Since (R1) had two falls on 01/26/2024 and was treated for severe sepsis, per Title 22 regulations 87211(a)(1)(B) any incident which threatens the welfare, safety or health of any resident a written report shall be submitted to the person responsible for the residents within seven days of the occurred events.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met.

Allegation: Staff did not dispense medication as prescribed

It was alleged that staff did not dispense medication as prescribed. This investigation consisted of interviews with staff and resident responsible party and records reviewed. LPA Lee also interviewed 4 facility staff who denies the allegations. On 03/04/2024 and 03/14/2024, LPA Lee attempted to interview (R1) who refused to be interviewed. It was learned that on 11/08/2023 resident 1 (R1) had an appointment for dental work and required that (R1) to be off (R1)’s Pradaxa medication for 48 hours prior to (R1)’s dental procedure.

Based on record review, on 11/06/2024 at 9:58 AM, City Creek was notified to hold (R1)’s Pradaxa medication (blood thinner) via email from (R1)’s responsible party. On 11/06/2023 at 12:16 PM, Resident Care Director Ashana Pillay emailed (R1)’s responsible party requesting for a doctor’s order for the Pradaxa hold.

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: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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: 05/15/2024
NARRATIVE
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 On 11/08/2023, City Creek received (R1)’s doctor’s order from Kaiser Permanente to hold (R1)’s Pradaxa. LPA Lee reviewed (R1)’s MAR log and (R1) was given Pradaxa medication on 11/06/2024 at 8:00 AM and Pradaxa medication was not given to (R1) on 11/06/2023 at 8:00 PM. (R1) Pradaxa medication was also not administer on 11/07/2023 and 11/08/2023. Furthermore, on 11/27/23 (R1)’s responsible party emailed City Creek notifying that (R1) has a dental appointment on 12/06/2023 at 11:00 AM and will need (R1)’s Pradaxa to be hold for two days prior to (R1)’s appointment. On 11/28/2023 at 12:25 PM, Resident Care Director Ashana Pillay, emailed (R1)’s responsible party stating that the screen shot send does not give an order stating to put medication on hold and that the cardiologist has to give specific order, stating to put Pradaxa on hold for dental procedure prior to appointment for two days starting date and end dates. On 12/01/2023 at 9:07 AM (R1)’s responsible party emailed, Resident Care Director Ashana Pillay to confirmed to hold (R1)’s Pradaxa medication. On 12/04/2023 at 8:25 AM, Resident Care Director Ashana emailed (R1)’s responsible party stating that she was not able to open the attachment that was sent to her and that she was waiting for the medical note from (R1)’s doctor. It was also learned that Resident Care Director Ashana Pillay reached out to (R1)’s responsible party to informed that the doctor’s order/letter was inadequate since it did not contain a date. Based on (R1)’s MAR log, it indicated that (R1)’s Pradaxa medication is suspended on 12/04/2023 to 12/05/2023; however, (R1)’s medication was administered to (R1) on 12/04/2024 for 8:00 AM pass and 12/05/2024 for 8:00 PM pass due to no doctor’s hold order in place.

Moreover, on 01/04/2024 at 7:35 AM, responsible party emailed Ashana to informed that (R1) has a dental appointment on 01/10/2024 with an attachment of a doctor’s order in placed dated on 12/22/2023 stating that every time patient has dental work: this patient” (R1) “will be undergoing dental treatment, In light of (R1)’s medical history, please proceed with dental treatment with the following precautions: Avoid epinephrine if local anesthesia is used. Prophylactic antibiotics are not recommended. Ok to hold Pradaxa for 2 days before the procedure if excessive bleeding is anticipated.” Based on charting records review dated on 01/08/2024 at 12:05 PM, (R1) will have Pradaxa held from 01/08/2024 to 01/10/2024 for dental procedure and that staff is aware. It was also charted on 01/08/2024 at 20:52, refused, on 01/09/2024 at 9:41 AM, resident refused, on 01/10/2024 at 5:41 PM, resident said no and told us to come back tomorrow, on 01/10/2024 at 8:08 PM, resident refused and on 01/10/2024 at 8:57 PM, resident refused. LPA Lee reviewed medication administration record and it was learned that on 01/08/2024 to 01/10/2024 (R1)’s medication Dabigtran Etexilate (blood thinner) medication was given to resident when there was a doctor’s order in placed to hold (R1)’s blood thinner medication.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

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

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87211(a)(1)(B)
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87211(a)(1)(B) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…
(D) Any incident which threatens the welfare, safety or health of any resident…

This requirement was not met as evidence by:
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Administrator agrees to ensure that residents responsible receives a written report of any incident that pertains to residents that may cause any serious injury and threatens the welfare, safety, or health of any residents.
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Based on interview and records review, the administrator did not ensure that (R1)’s responsible party received a written report in regards to (R1)’s fall which resulted in (R1) being hospitalized on both 01/26/2024 to 01/29/2024 and 04/13/2024 to 04/17/2024. This poses a potential health and safety risk to resident in care.
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 Administrator will review regulations cited/and regulation 87211 Reporting Requirements and write a statement of acknowledgement of reading and understand the regulation. POC will be emailed to LPA Lee by POC due date 05/20/2024 by end of day 5:00 PM.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidence by:
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Administrator agrees to ensure that all resident’s physicians are followed per physician’s order. Administrator will review regulations cited/and regulation 87465 Incidental
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Based on records review, the administrator did not ensure that (R1)’s medication for Dabigtran Etexilate (blood thinner) was put on hold for 01/08/2024 to 01/10/2024 according to physician’s order since (R1) had a dental extraction on 01/10/2024. This poses an immediate health and safety risk to resident in care.
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Medical and Dental Care and write a statement of acknowledgement of reading and understand the regulation. POC will be emailed to LPA Lee by POC due date 05/24/2024 by end of day 5:00 PM.

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

DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5