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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 08/05/2024
Date Signed: 08/05/2024 09:37:05 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
05/07/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240507133821
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:
08/05/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Caleb Summerhays and Mel DearingTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Facility staff do not assist residents with ADLs.
Residents calls are not responded within a timely manner.
INVESTIGATION FINDINGS:
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On 08/05/2024 at 8:46 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 findings for the allegations above. The current census is 116. A brief interview with conducted with Nurse Mel.

Allegation: Facility staff does not assist residents with ADLs and residents’ calls were not responded within a timely manner.

It was alleged that facility staff does not assist residents with ADLs and that residents’ calls were not responded within a timely manner. This investigation consisted of records reviewed, interviews with staff and residents. LPA Lee interviewed 6 out of 9 residents who has concerns with their ADLs not being met and their calls not responded within a timely manner.
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: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
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 4
Control Number 27-AS-20240507133821
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: 08/05/2024
NARRATIVE
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 Based on the facility shower log for the month of April it was learned that four residents were not receiving showers by the facility. It was also learned that some residents did not receive shower a week after the previous shower. LPA Lee also reviewed End of Shift Report and it was learned that on 04/19/2024 resident 1 (R1) was upset because the shower schedule is inconsistent and that (R1) wanted a shower. Based on observations on 07/29/2024 at 9:14 AM, LPA Lee observed (R1) and (R2) call lights turned. It was learned that (R1) was waiting to get assistance with toileting and (R2) was waiting to get assistance with changing (R2) incontinence brief. At 9:26 AM, LPA Lee observed two Resident Aid (RA) walked by both (R1) and (R2)’s room without acknowledging and checking on both resident even though their call lights were turned on. At 9:46 AM, Administrator Assistance, Katelyn Becker approached LPA Lee and LPA Lee informed Katelyn about what LPA Lee have observed and that two residents needed assistance with their ADLs. At 9:54 AM (R1) stopped a (RA) who walked by her to get assistance. It took 37 minutes before a (RA) assisted (R1) with toileting. At 9:54 AM, LPA Lee observed a (RA) going into (R2)’s room to assist (R2) with changing (R2)’s incontinence brief. It took 40 minutes before (R2) received the assistance with changing (R2)’s incontinence brief. Per (R1)'s LIC 602 Physician Report (R1) needs assistance with set for toileting. Per (R2) LIC 602 Physician Report it was learned that (R2) wears brief and needs one person assistance for toileting needs.

Moreover, LPA Lee and administrator Caleb toured the facility for an annual inspection on 07/29/2024 and observed resident room 213 and room 110 to have a very strong urine odor. LPA Lee pointed out to administrator regarding the strong urine odor in both rooms and LPA Lee asked administrator what does it mean if a resident's room has a strong urine odor and administrator Caleb stated, "it means the resident are not getting changed or cleaned."

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 Nurse Mel 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: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20240507133821
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: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
87303(i)(1)(B)
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87303(i)(1)(B) Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
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The administrator will conduct an audit and ensure additional training with facility staff to ensure that all residents call lights are answered in a timely manner. Administrator also agrees to submit proof of training and the training materials used along with staff sign in sheet.
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This requirement was not met as evidence by:
Based on 6 out 9 interviews with residents’ facility staff are not responding to residents ‘call light in a timely manner. Based on observations on 07/29/2024, two residents waited over 30 minutes to received assistance with their ADLs needs.
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Administrator will also review regulations being cited today and write a statement of acknowledging. POC will be email to LPA Lee at pang.lee@dss.ca.gov by POC date 08/16/2024 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: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20240507133821
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: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
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.

This requirement was not met as evidence by:

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Administrator agrees to conduct personal rights training for all staff, by POC Date 08/16/2024. Facility Staff agrees to email training documents and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC date 08/16/2024 end of day 5:00 PM.
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Based on interviews and observation, the facility did not attend to two residents ADLs needs in a timely manner. (R1) waited for 37 minutes before a staff assisted (R1) with toileting needs and (R2) waited 40 minutes to get (R2)’s incontinence brief change. This posed an immediate health and safety risk to residents in care.
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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: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4