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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:03:20 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
12/13/2024 and conducted by Evaluator Pang Lee
COMPLAINT CONTROL NUMBER: 27-AS-20241213111216
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:
01:30 PM
MET WITH:Leslie PadillaTIME COMPLETED:
02:16 PM
ALLEGATION(S):
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Facility staff are not providing good quality food to residents in care.
INVESTIGATION FINDINGS:
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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 are not providing good quality food to residents in care. The investigation included staff and resident interviews, a review of records, and on-site observations. LPA Lee interviewed 5 out of 7 residents, who raised concerns about the food quality. They mentioned that portion sizes were too small, the food was often served cold, and it didn’t meet their special dietary needs. In an interview with Administrator Caleb Summerhays, it was revealed that facility staff 1 (S1) received a written warning for not following residents’ special dietary orders.

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 3
Control Number 27-AS-20241213111216
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
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According to the records, S1 had indeed received a corrective/disciplinary action for not following the special diet guidelines provided by residents' physicians and the City Creek clinical team and for not providing an adequate portion of food to residents in care. Additionally, it was learned that the facility lacked a full-time employee with qualified training since the facility does have a nutritionist, dietitian, nor a consultation with a qualified professional. During the facility's kitchen inspection on 12/17/24, LPA Lee observed multiple issues. In the walk-in freezer, there were containers that lacked lids and were sealed with saran wrap. These containers also did not have any labels indicating the date the food was placed inside or an expiration date. The items observed included:

· A commercial food storage container with bacon bites.
· A commercial food storage container with three types of cheese.
· 5 pounds of sour cream.

When questioned about the protocol, S1 confirmed that food should be stored in labeled containers with lids, not saran wrap, and should include the date the food was stored. During a follow-up visit on 01/29/25, LPA Lee conducted another inspection of the walk-in freezer and found a bucket tray labeled with the date 12/14/24. The bucket contained several unopened packages of boiled eggs with expiration dates of 03/25/25. Also present were bags of bacon bites and ham bites in Ziploc bags, but they lacked open dates or expiration dates. Furthermore, LPA Lee observed unsanitary conditions in the kitchen, including cooking stoves and ovens covered with grime, grease, and food debris. The sink was filled with a dirty pot and appeared unsanitary. Additionally, there was a bag of dirty rags on the floor.

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: 2 of 3
Control Number 27-AS-20241213111216
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
87555(a)
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87555 General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared, and served in a safe and healthful manner.

This requirement was not met as evidence by:
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Administrator agrees to conduct outside training from a third party for general food service training for all staff, by
POC Date 02/19/25. Administrator agrees to email training materials used and sign
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Based on interviews, observations and records review, the facility staff did not provide good quality of food to residents in care. This posed an immediate health and safety risk to residents in care.
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in and out sheet to LPA Lee at
pang.lee@dss.ca.gov by POC 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.
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)
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