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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 05/06/2025
Date Signed: 05/06/2025 09:35:33 AM

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
11/18/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241118154836
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: 110DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Caleb Summerhays and Katelyn FloresTIME COMPLETED:
08:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not assist resident with meeting their medical appointments resulting in resident's death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/05/25 Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs 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 finding for the allegation above. The current census is110.

It was alleged that facility staff did not assist resident with meeting their medical appointments resulting in resident's death. Throughout the course of the investigation, the Department conducted interviews, reviewed facility documents, and reviewed hospital records. The investigation revealed resident 1 (R1) was receiving dialysis treatment at Davita Dialysis Center. R1 had appointments scheduled for the following dates: 12/07/23, 12/09/23, and 12/12/23. A records reviewed indicated that R1 missed all three of the appointments. Per R1’s Certificate of Death, R1 died on 12/12/23 at 2134 hours.

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

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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-20241118154836
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: 05/06/2025
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
 R1’s immediate cause of death is noted as “end stage kidney disease” and “type 2 diabetes.” The duration of the end stage kidney disease was noted as six months. The duration of the type 2 diabetes was noted as years. R1’s Primary Care Physician (PCP) was not able to say for certain if R1’s missed appointments caused R1’s death or contributed to R1’s death.

The investigation revealed the preponderance of evidence standards have not been met; therefore, 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: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
11/18/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241118154836

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: DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Caleb Summerhays and Katelyn FloresTIME COMPLETED:
08:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not inform resident's responsible party about resident's change of condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT HAS BEEN AMENDED TO CHANGE FROM UNSUBSTANTIATED TO SUBSTANITEATED AND SIGNED BY LPA LEE AND DESIGNEATED FACILITY STAFF.
On 05/05/25 Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs met with XXXXX and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is112.

It was alleged that facility staff did not inform resident's responsible party about resident's change of condition. During the investigation, the Department conducted interviews with facility staff and reviewed Resident 1’s (R1) records. The investigation revealed that R1 was receiving dialysis treatment at Davita Dialysis Center and had appointments scheduled for 12/07/23, 12/09/23, and 12/12/23. All three appointments were missed. Additionally, it was learned that prior to R1’s passing, the resident had stopped eating.

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

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241118154836
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: 05/06/2025
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
In interviews with Administrator Caleb Summerhays and Resident Care Coordinator Leslie, staff acknowledged that R1’s responsible party had not been informed of the resident’s refusal to attend dialysis or of the missed appointments. It was also learned that the facility did not notify the family about the resident’s change in condition. A review of the records revealed that there was no documentation of any communication with R1’s family regarding the resident’s change in condition, refusal of dialysis, and the missed appointments.

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 Tasha and Melissa 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: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20241118154836
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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
CCR
87466
1
2
3
4
5
6
7
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…

This requirement was not met as evidenced by
1
2
3
4
5
6
7
Administrator shall submit plan to ensure the responsible party is notified of change in condition in a timely manner. An In-Service Training shall be conducted for all direct care staff which addresses the procedures put in
8
9
10
11
12
13
14
Based on interviews and records review, facility staff admitted that R1’s change in condition was not communicated to R1’s responsible party and documented, this poses a potential risk to residents in care.
8
9
10
11
12
13
14
place to ensure that resident’s responsible party are notified of the residents change in condition. A copy of signatures of staff attending training and an outline of training shall be submitted to CCL by POC date 05/16/25 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: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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