<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 02/04/2025
Date Signed: 02/04/2025 01:59:10 PM

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
11/26/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241126134828
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: 116DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Leslie Padilla TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff not responding to residents' call lights
Facility staff not meeting incontinence care needs of residents.
Facility staff not properly addressing scabies in the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/04/25 at 12:12 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Resident Care Coordinator Leslie Padilla 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 116.

It was alleged that facility staff not responding to residents' call lights in a timely manner. The investigation included interviews with staff and residents, a review of records, and on-site observations. LPA Lee interviewed 6 out of 8 residents, who expressed concerns about staff not promptly responding to their call lights. Residents reported that it often takes between 30 minutes to an hour for staff to respond, or sometimes there is no response at all. Interviews with facility staff revealed that each hall is assigned one resident aide (RA), and the facility has three halls (Hall 1, Hall 2, and Hall 3).

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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-20241126134828
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: 02/04/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Residents activate the call system by pulling a string in their room, which lights up an indicator outside the room to alert staff that assistance is needed. 4 out of 6 staff members admitted that the facility’s call system is outdated and inefficient, as it relies solely on visual signals rather than sound. This means that if an RA is assisting another resident in their room, the resident who needs help must wait until the RA is available or if another staff member notices the light. Based on records review the facility does not have a system in place to track the call system's performance, other than periodic inspections to ensure it is operational. During the investigation, LPA Lee observed two separate incidents where residents were unable to get timely assistance. On 12/03/24 at 1:46 PM, LPA Lee observed a resident in room 309 needing help, but no RA attended to them until LPA Lee approached Assistant Administrator Katelyn. Upon inspecting the call light, LPA Lee discovered it was not in good working order. A similar issue was observed on 01/29/25, when a resident in room 206 required assistance, but their call light was also found to be malfunctioning. LPA Lee raised these concerns with Administrator Caleb Summerhays and Assistant Administrator Katelyn Flores, specifically addressing the malfunctioning call lights and the lack of response when the lights are not functioning properly.

It was alleged that staff were not meeting the incontinence care needs of residents. The investigation included interviews with staff and residents, as well as observations. LPA Lee interviewed 5 out of 8 residents, all of whom expressed concerns about the long wait times for incontinence care from resident aide (RA) staff. Residents mentioned using the call system to request assistance, but RA staff would take 30 minutes to an hour, or sometimes not respond at all, before providing help. During an observation on 01/29/25, LPA Lee noticed a strong urine odor in resident room 106 and a mild urine odor in resident room 213. In an interview with facility staff, it was revealed that the resident in room 106 requires assistance with incontinence care and tends not to use the urinal. LPA Lee recommended that the resident in room 106 may need additional oversight, such as reminders for incontinence care and more frequent cleaning in the room to reduce the strong urine odor.

It was alleged that the facility staff did not properly address scabies in the facility. The investigation involved interviews with staff and residents, as well as a review of facility records. LPA Lee interviewed 4 out of 8 residents, who either raised concerns about scabies in the facility or mentioned hearing about other residents having scabies.

Continued LIC 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20241126134828
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: 02/04/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Lee also spoke with facility staff, who stated that it is unclear if there are any cases of scabies since the residents that was sent to the ER for itchiness did not undergo a scratch or skin test and that it may be scabies. Facility staff did confirm that scabies policies and procedures had been implemented. However, it was discovered that while some residents were placed under isolation precautions, they were not actually isolated. Instead, they continued to share rooms with roommates, potentially exposing others to scabies. According to an incident report dated 11/21/24, one resident was sent to the ER for itchiness and later returned to the facility with treatment for scabies. Additionally, incident reports from 01/08/25 and 01/12/25 indicated that three other residents were also sent to the ER for scabies treatment or possible exposure. The investigation revealed that the facility did not follow the physician's orders for timely follow-up after ER visits. For example, Resident 1 (R1) was supposed to follow up with their primary care provider (PCP) within 5 days, but the facility did so 7 days later. Resident 2 (R2) was supposed to follow up within 3 days but was not seen by a PCP until 5 days later. The facility’s City Creek Scabies Policy, dated 12/01/23, specifies in Procedure #3 that physicians' treatment protocols should be followed, but the facility did not follow-up with PCP in a timely manner. Additionally, the policy on page 358 under Treatment Procedure (c.i.) states that "Contact Precautions should be initiated until 24 hours after the first treatment," yet the residents were not placed under isolation precautions and continued to share rooms with roommates. It was also learned that the facility didn’t consult with local health department to report and possible exposure of scabies in the facility.

Based on information and interview gather there is a preponderance of evidence to prove the alleged violations occurred, as a result the allegations are 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 and a copy of this LIC 9099, LIC 9099-D page and appeal rights was provided to facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241126134828
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: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2025
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
87468.1(a)(2) Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all the following personal rights:
(2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agrees to conduct outside training from a third party for personal rights training for all staff, by POC Date 02/12/25. Administrator agrees to email training materials used and sign in and out sheet to LPA Lee
8
9
10
11
12
13
14
Based on interviews and observation, the facility staff did not respond to residents call lights where two residents call lights was in despair and resident was waiting to be assisted. This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
at pang.lee@dss.ca.gov by POC end of day 5:00 PM. Administrator will also conduct call lights inspections and provided reports to LPA Lee
Type B
02/12/2025
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
87625(b)(3) Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.

This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agrees to conduct outside training from a third party for Managed Incontinence training for all staff, by POC Date 02/12/25.
8
9
10
11
12
13
14
Based on interviews and observation, the facility staff did not meet incontinence needs of the residents based on interviews and where two residents’ room had a strong and mild urine odor. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Administrator agrees to email training materials used and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC end of day 5:00 PM.
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: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20241126134828
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: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2025
Section Cited
CCR
87470(b)(3)
1
2
3
4
5
6
7
87470(b)(3) Infection Control Requirements

(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply:
(3) There shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others.

This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agrees to conduct outside training from a third party for Managed Incontinence training for all staff, by
POC Date 02/12/25.
8
9
10
11
12
13
14
Based on interviews and records review, the facility staff did not properly address scabies in the facility where 4 resident was sent out to ER for scabies and returned to the facility without being isolated by other residents as well as not notifying public health. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
 Administrator agrees to email training materials used and sign in and out sheet to LPA Lee at
pang.lee@dss.ca.gov by POC end of day 5:00 PM.

1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5