342700835-2-26-2024-27-AS-KHOS-D8HQQY-20240826122306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 02/26/2024
Date Signed: 02/26/2024 12:16:17 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
09/14/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20230914115212

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: 112	DATE:	02/26/2024
		UNANNOUNCED	TIME BEGAN:	10:47 AM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Due to lack of supervision residents wandered away

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findings regarding current complaint allegations . LPA Ivey Canady explained the purpose of the visit and was met by Caleb Summerhays
The Department has determined the following as it relates to the complaint allegations: Due to lack of supervision residents wandered away
On 2/26/2024 LPA Ivey Canady conducted an interview with facility administrator regarding current facility allegation. According to interview with facility staff and facility record review from documents received on 9/15/2023, R1 and R2 were accounted for during facility room rounds and R1 did not leave the line of site from facility staff. It was learned that the facility has installed a Wanderguard system to limit occurances of resident AWOLS. Based on a properderance of the evidence the allegation Due to lack of supervision, residents wandered away is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.Per California Code of Regulations (CCRs) - Title 22 no deficiencies cited. Exit interview was held and a copy of report was given to facility administrator

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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

LIC9099 (FAS) - (06/04)

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