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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 11/15/2021
Date Signed: 11/15/2021 04:57:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CITY CREEK ASSISTED LIVINGFACILITY NUMBER:
342700835
ADMINISTRATOR:LITTERER, KEVINFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 599-7033
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:121CENSUS: 104DATE:
11/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a case management visit. LPA Valerio was screened for COVID-19 symptoms prior to being allowed entry into the facility. Staff confirmed residents and staff have not displayed any signs or symptoms of COVID-19 in the last 10 days. LPA Valerio explained the purpose of the visit and was met by Caleb Summerhays.

During a complaint investigation (27-AS-20210927154924), LPA Valerio discovered that Resident 3 (R3) did not have a completed Centrally Stored Log on file.

During a complaint investigation (27-AS-20210927154924), LPA Valerio learned from Staff 1 (S1) that S1 did not report medication errors that occurred on 09/25/21.

Due to above found information, deficiencies are being cited during today's visit and can be found on LIC 809-D. Failure to correct deficiencies may result in civil penalties. Exit interview was held, and a copy of the report was given to staff Caleb Summerhays.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CITY CREEK ASSISTED LIVING
FACILITY NUMBER: 342700835
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2021
Section Cited

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87211Reporting Requirements (a) Each licensee...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement was not met as evidenced by:
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Based on interviews, Staff 1 confirmed that the facility did not report missed medications for residents on 09/25/21, which poses a potential health and safety risk to residents in care.
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Type B
11/29/2021
Section Cited

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87506 Resident Records b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications... This requirement was not met as evidenced by:
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Based on record review, the facility did not have a completed centrally stored log on file for resident 3, which poses a potential 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021
LIC809 (FAS) - (06/04)
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