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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 05/02/2025
Date Signed: 05/02/2025 01:22:13 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
03/24/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250324145954
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: 112DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Caleb Summerhays and Katelyn FloresTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not allow resident to participate in planning their own care
Facility staff do not maintain facility free of odors from incontinence
INVESTIGATION FINDINGS:
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On 05/02/25 Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and Health Services Director Katelyn Flores 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 112.

It was alleged that staff did not allow resident to participate in planning their own care. The investigation included interviews with staff, residents, and external agencies, as well as a review of relevant records. LPA Lee interviewed 6 out of 9 residents, all of whom reported no concerns regarding their involvement in care planning. Additionally, LPA Lee interviewed all 4 staff members, who denied the allegation, and both external agency representatives, who also denied the claim. Resident 1 (R1) stated in an interview that the facility does allow R1 to participate in R1’s care planning.

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

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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
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
03/24/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250324145954

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: 112DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Caleb Summerhays and Katelyn FloresTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Staff did not allow visitor
INVESTIGATION FINDINGS:
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On 05/02/25 Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays and Health Services Director Katelyn Flores 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 112.

It was alleged that facility staff did not allow a visitor to see Resident 1 (R1). The investigation included interviews with 3 facility staff and R1, as well as a review of facility records. LPA Lee interviewed all three facility staff members, who confirmed that on 03/24/25, two individuals from an external agency came to visit R1. However, staff admitted that R1 was not informed of the visitors' presence, and as a result, the visitors did not have the opportunity to meet with R1. During an interview, R1 stated that R1 no longer wish to attend the day program but confirmed to LPA Lee that R1 would like to receive visitors from the day program if any were to come.
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250324145954
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: 05/02/2025
NARRATIVE
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 R1 also confirmed that R1 was not aware of any attempted visit from the day program on 03/24/25. According to R1’s Admission Agreement (page 2, under House Rules/Facility Policies), “visiting hours are open and all residents are encouraged to accept visitors at a time that works best for their individual needs.” Additionally, the facility’s Plan of Operation (page 15, under Personal Rights) states that residents have the right “to have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.” Therefore, the facility did not notify R1 of their visitors on 03 24/5, in violation of both the Admission Agreement and the facility’s Plan of Operation.

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 Health Services Director Flores and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250324145954
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: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 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:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met as evidence by:
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The Administrator agrees to provide training to facility staff on Personal Rights, specifically focusing on residents' rights related to visitation. The Administrator will also provide LPA Lee with a staff training sign-in sheet, along with copies of the training materials used.
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Based on interviews and records review the facility did not notify R1 of their visitors on March 24, 2025, in violation of both the Admission Agreement and the facility’s Plan of Operation. This posed an immediate risk to residents in care.

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Additionally, the Administrator will review the applicable regulation and submit to LPA Lee a signed statement acknowledging that they have read and understood the cited regulation. The Plan of Correction (POC) is due to LPA Lee by May 16, 2025, no later than 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: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250324145954
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: 05/02/2025
NARRATIVE
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 Both outside agency representatives confirmed that R1 is actively involved in R1’s care plan and that regular meetings are held with R1 and facility staff. R1 expressed no concerns. A review of R1’s Patient's Rights form dated on 09/10/24 also confirmed this, showing signatures from R1, R1's case manager, placement agency and administrator Caleb. Moreover, on 03/05/25, the facility sent an email to the day program (DP) informing them that R1 would no longer be utilizing their services and that R1 could be discharged from the program. According to a service note from the external agency, R1 verbally expressed that R1 no longer wished to attend day program. This decision was coordinated with Staff 1 (S1) from Social Services at City Creek Assisted Living, and the discontinuation of services was discussed. Additionally, it was discovered that R1 wrote and signed a letter dated 03/14/25, stating, that R1 doesn't want to go to day program.

It was alleged that facility staff do not maintain the facility free of odors from incontinence. The investigation included observations, as well as interviews with staff, residents, and two external agency representatives. On 04/01/25, LPA Lee conducted an unannounced visit and toured the facility, including Halls 1, 2, and 3. During the visit, housekeepers were observed cleaning residents’ rooms. LPA Lee inspected 10 resident rooms and did not observe any malodors or incontinence related odors. During today’s visit, 05/01/25, LPA Lee toured the facility with housekeeping supervisor Shante Reyes and no incontinence related odors were observed. Moreover, LPA Lee observed Housekeepers throughout the facility cleaning. LPA Lee interviewed 6 of 9 residents, all of whom reported no concerns regarding facility cleanliness or odors. All 4 interviewed staff members denied the allegation. It was learned that there are two housekeepers assigned in each hall, three halls total during the shift of 7:00 am to 3:30 PM from Monday to Saturday and an additional janitor from 2:00 PM to 6:00 PM, Monday to Friday to clean residents’ rooms and the facility throughout the day. Additionally, two external agency representatives reported having no concerns and confirmed they had not witnessed any odor issues related to incontinence during their visits.

Based on information and interview gather there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the investigation revealed the preponderance of evidence standards have not been met. The above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.


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

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5