342700835-7-29-2024-27-AS-PLEE-D7MV3S-20240729160513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:05:24 PM

Document Has Been Signed on 07/29/2024 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	CALEB SUMMERHAYS		FACILITY TYPE:	740
ADDRESS:	6254 66TH AVENUE		TELEPHONE:	(916) 393-2324
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	121	CENSUS: 114	DATE:	07/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Caleb Suumerhays and Mel Dearing		TIME COMPLETED:	01:30 PM

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	On 07/29/2024 at 8:24 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Caleb Summerhays and Nurse Mel Dearing. LPA explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 7026521740 and will expire on 11/17/2025. The current census is 114 with 3 Med-Techs, 5 caregivers, 2 house keepers, 1 laundry attendant, 4 managers and 1 nurse during today’s visit. This facility is a single story building licensed to serve one hundred twenty-one (121) non-ambulatory residents and approved for 12 hospice waivers. LPA and administrator Caleb inspected the physical plant including but not limited to the lobby area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, residents’ lounge/activities area and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be clean. LPA observed the facility to not be free of odor. LPA observed resident room #213 and #110 to have a very strong urine odor in the room. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA observed the last inspection for the kitchen hood conducted on 02/14/2024. LPA observed knifes and toxins kept locked and inaccessible to residents in care. Hot water temperature was measured at 120.1 degrees Fahrenheit in resident’s bathroom sink. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in hall 1, hall 2 and hall 3 and was last serviced on 07/19/2024. All fire exits are free of obstacles and last fire drill was completed on 06/18/2024. LPA observed the facility has two public telephones in the hallway to the dining room. Facility thermostat observed at 71 degrees Fahrenheit. LPA checked medication storage and found medication to be locked away and inaccessible to residents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/29/2024

NARRATIVE

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LPA reviewed and compared 9 out of 114 medication administration record (MAR) with client’s medication and it was complete. The first aid kit was checked, and it did contain all of the required components. LPA requested residents and staff files for review. LPA Lee reviewed 9 out of 114 resident files and they were complete. LPA reviewed 5 staff files and they were also complete. Staff have criminal record clearance and are associated to the facility.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 08/02/2024 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610D Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2024 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87625(b)(3)

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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the administrator did not comply with the section cited above. LPA and administrator Caleb observed resident bedroom # 213 and #110 to have a strong urine odor, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Administrator agrees to ensure that all residents room are free from urine odor. Administrator will conduct a cleaning schedule to ensure room # 213 and 110 are free of any odor and provide LPA Lee the cleaning schedule by POC date 07/02/2024 by end of day 5:00 PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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