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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 11/03/2021
Date Signed: 11/03/2021 03:39:18 PM

Document Has Been Signed on 11/03/2021 03:39 PM - It Cannot Be Edited

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: 100DATE:
11/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA Valerio was screened for COVID-19 symptoms prior to being allowed entry. Administrator Caleb Summerhays confirmed no signs or symptoms of COVID-19 in the last 10 days.

Incident occurred on 10/28/2021 - Resident 1 (R1) left the facility to buy cigarettes. Staff saw that R1 signed out and immediately went to look for R1. R1 was spotted by staff walking to the store. R1 stated R1 wanted to buy cigarettes. According to R1's LIC 602, R1 cannot leave the facility unassisted. According the Administrator Caleb, R1 has done this in the past based on the store owner knowing the resident.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited and can be found on LIC 809-D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was held, and a copy of the report was given to Administrator Caleb.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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Document Has Been Signed on 11/03/2021 03:39 PM - It Cannot Be Edited


Created By: Christina Valerio On 11/03/2021 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2021
Section Cited
CCR
87464(f)(1)

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87464 Basic Services (f)Basic services shall...include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code 2(c). This requirement was not met as evidenced by:
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The licensee sent Community Care Licensing a incident report with 24 hours of the incident. The licensee plans on conducting a meeting with R1's responsible party to discuss the awol, create a behavior plan, and assess her medications. The staff will review residents who are unable to leave and ensure residents do not leave facility unassisted. Information to be seny by POC.
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Based on record review and interview, the licensee did not ensure R1 did not leave the facility unassisted, which poses an immediate health and safety risk to persons 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 Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
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