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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 08/23/2024
Date Signed: 08/23/2024 11:03:00 AM

Unfounded


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 Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230914115212
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: 117DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
11:18 AM
ALLEGATION(S):
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9
Residents consumed illegal drugs (Fentanyl) while in care.
INVESTIGATION FINDINGS:
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On 08/23/2024 at 10:03 AM, Licensing Program Analysts (LPAs) Pang Lee and Holly Williams arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays 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 117. A brief interview with conducted with the administrator.

Allegation: Residents consumed illegal drugs (Fentanyl) while in care
It was alleged that residents consumed illegal drugs (Fentanyl) while in care. This investigation consisted of records reviewed, interviews with staffs and resident. Based on the facility’s medication list, the facility did not have any residents prescribed Fentanyl during August of 2023. It was also learned that if a resident is prescribed Fentanyl, it is typically prescribed via a “patch” which the resident places on their shoulder. The patch slowly releases the Fentanyl to aid in pain management.

Continued LIC 9099-C

Unfounded
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: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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-20230914115212
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: 08/23/2024
NARRATIVE
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Based on interview, multiple facility staff interviewed denied ever giving R1 Fentanyl. Moreover, R1 denied the facility staff ever giving R1 Fentanyl. R1 denied knowing taking Fentanyl. R1 admitted to smoking Marijuana at the facility. R1 smokes outside in a designated area specifically for smoking Marijuana. R1 stated the day R1 went to the hospital R1 met a “friend” who gave R1 a “baggie” full of Marijuana. R1 stated that R1 believes the baggie the friend gave R1 might have been “laced” with Fentanyl and that is why R1 tested positive at the hospital.

This agency has investigated the complaint alleging " residents consumed illegal drugs (Fentanyl) while in care". We have found that the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the facility.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited.


A copy of this report was provided alone with the LIC 811, the Confidential Names List.
Exit interview.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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 Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230914115212

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: 117DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Caleb SummerhaysTIME COMPLETED:
11:18 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/23/2024 at 10:03 AM, Licensing Program Analysts (LPAs) Pang Lee and Holly Williams arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Caleb Summerhays 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 117. A brief interview with conducted with the administrator.

Allegation: Staff did not seek medical attention for resident in a timely manner
It was alleged that facility staff did not seek medical attention for resident in a timely manner and resident became septic while in care. This investigation consisted of records reviewed, interviews with staffs and residents. Based on records provided by the facility R2 showed signs of a rash under both breast on 05/23/2023. The facility staff kept the area of the rash clean, dry, and applied various rash medication on it such as creams and powders. The medications helped initially but then the rash would get worse. On 06/18/2023, R2 was sent to UC Davis as the rash continued to get worse.

Continued LIC 9099-C
Unsubstantiated
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: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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 4
Control Number 27-AS-20230914115212
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: 08/23/2024
NARRATIVE
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 R2 returned to the facility and the same treatment was continued which initially worked but again ultimately the rash got worse. R2 was sent to UC Davis again on 07/09/2023 and then discharged back to the facility. On 07/15/2023, R2 was sent to UC Davis again for the rash. This time, R2 was admitted into the hospital. R2 was released to a rehab center for approximately one month. When R2 returned to the facility, the rash was gone. The rash has not returned.

Per staff interviewed, R2 is completely bedbound as R2 has sustained a few falls and R2 is now afraid to get out of bed. R2 is given complete showers twice a week. R2 requires assistance with all ADLs. When the rash presented under R2 breast, staff would clean R2’s breast area daily with warm water, soap, and a rag. Staff continued to clean R2 daily and apply the cream and ointments per the doctors’ orders. Based on records and staff statements, staff were aware of the rash and continued treatment per the in-house doctor’s orders. There were gaps in R2 being seen in person by a physician which may have resulted in a different outcome. Facility staff attempted to have doctor treat R2 in person, but the doctor was “unavailable” or “hard to reach” resulting in the staff sending R2 to the hospital on three different occasions. Based on evidence in this report, the case is unsubstantiated.

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.


Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited.


A copy of this report was provided, along with the LIC 811, the Confidential Names List.
Exit interview.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4