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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 06/24/2024
Date Signed: 06/24/2024 01:21:16 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
03/29/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240329100952
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:
06/24/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Caleb Sumerhays and Mel DearingTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff did not report a fall to family
INVESTIGATION FINDINGS:
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On 06/24/2024 at 1:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Caleb Sumerhays and 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 Caleb and Mel.

Allegation: Facility staff did not report a fall to family
It was alleged that facility staff did not report a fall to family. This investigation consisted of records reviewed and interviews with staff and residents. LPA Lee interviewed 8 out of 9 residents who did not witness or heard (R1) having a fall. Moreover, 5 out of 5 facility staff did not witness and heard (R1) having a fall. Based on record review there was no documentation of (R1) having any fall in the month of February to April of 2024.

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: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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-20240329100952
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: 06/24/2024
NARRATIVE
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Based on the interviews and statements obtained during the investigation process, the allegation has not been corroborated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited.
A copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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
03/29/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240329100952

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:
06/24/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Caleb Sumerhays and Mel DearingTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Facility staff does not assist in feeding
Facility staff do not provide medications on time
INVESTIGATION FINDINGS:
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On 06/24/2024 at 12:15 PM , Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Caleb Sumerhays and 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 113. A brief interview with conducted with Caleb Sumerhays and Mel Dearing.

Allegation: Facility staff does not assist in feeding
It was alleged that facility staff does not assist in feeding. This investigation consisted of records review and interviews with staff, residents, and outside agencies. Based on resident 1 (R1) Individual Service Plan dated on 02/13/2024, on page Section C: Page 2 it states that (R1) needs extensive assistance with feeding and is not able to see what is in front of (R1) and needs cuing both physical and verbal to orient (R1) to (R1)’s food in front of (R1). LPA Lee interviewed 4 out of 5 facility staff who confirmed that (R1) didn’t received one on one feeding after (R1) came back from the VA Hospital on 03/28/2024. 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.
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: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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-20240329100952
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: 06/24/2024
NARRATIVE
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Allegation: Facility staff do not provide medications on time.

It was alleged that facility staff do not provide medications on time. This investigation consisted of records reviewed, and interviews with staff and residents. LPA Lee interviewed 6 out of 9 residents who stated that they are not getting their medications and does have concerns regarding medications. Based on (R1) Medication Administration Record review it was learned that for the month of February 2024 (R1) didn’t receive the following medications for the following dates: Iepezil HCL 10 MG Tablet Tab: take 1 tab by mouth at bedtime for 02/23/2024, Dorzolamide Timolol 22.3-6.8, install 1 drop in each eye twice daily for glaucoma for 02/05/2024, Gabapentin, take 1 cap by mouth three times daily for 02/01/2024, 02/08/2024, 02/11/2024, 02/13/2024, 02/18/2024, 02/23/2023, Latanoprost 0.005%, instill 1 drop in each eye every evening for glaucoma for 02/23/2024, Brimonidine Tartrate Ophth 0.2% drops, install 1 drop in right eye twice daily for glaucoma for 02/07/2024, 02/08/2024, 02/09/2024, 02/10/2024, 02/11/2024, 02/15/2024, 02/16/2024, 02/19/2024, 02/20/2024, 02/232024,02/24/2024 and 02/25/2024. Moreover, for the month of March 2024, (R1) also didn’t received the following medications for the following dates: Gabapentin 300 MG Capsule, take 1 Cap by mouth three times daily for breve pain for 03/02/2024, 03/04/2024, 03/20/2024, 03/26/2024 and Brimonidine Tartrate 0.2%, instill 1 drop in right eye twice daily for glaucoma for 3/01/2024, 03/04/2024, 03/05/2024, 03/08/2024, 03/21/2024, 03/22/2024, 03/24/2024, 03/26/2024 to 03/31/2024.

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 Caleb and Mel and a copy of this LIC 9099, LIC 9099-D page and appeal rights were provided to the facility.

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

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240329100952
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: 06/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2024
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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Licensee/administrator agrees to conduct Incidental medical and dental training for all Med-tech and any staff that handles residents’ medications. Licensee/administrator will email LPA Lee training materials and staff sign in sheet by POC date 07/01/2025.
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Based on interviews and records review: the licensee did not ensure that (R1) received (R1)’s medications as prescribed. (R1) MAR log was missing initial for multiple medications for the month of February 2024 and March 2024. It is unknown if medication were administered to (R1). This posed an immediate health and safety risk to R1.
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Type A
06/24/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful, and comfortable accommodations, furnishings and equipment.
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Licensee/administrator agrees to ensure that all residents who requires assistance with feeding are receiving assistance. A statement of understanding and acknowledge of the regulation cited will be emailed to LPA Lee by POC date 07/05/2024 by end of day 5:00 PM.
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This requirement was not met as evidence by:
Based on interviews and records review: the licensee/administrator did not ensure that (R1) was assisted with feeding per (R1)’s Individual Service Plan. This posed an immediate health and safety risk to R1.
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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: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5