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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 12/09/2021
Date Signed: 12/09/2021 03:08:13 PM

Document Has Been Signed on 12/09/2021 03:08 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:BRIDGETTE CRUMMIEFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 121CENSUS: 103DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
04:00 PM
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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 with temperature taken prior to being allowed entry. Facility staff confirmed 0 residents and staff have displayed any signs or symptoms of COVID-19 in the last 10 days.

After entering, LPA Valerio walked around the facility to ensure compliance with Title 22 regulations. LPA inspected the fire extinguishers in halls 1, 2, and 3. Fire extinguishers were last checked on 08/11/2020. LPA Valerio later met with Program Director Caleb and informed him about the deficiency.

Per California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies are being cited on the attached LIC 809-D. Program Director was notified that an assessment of an immediate $500 civil penalty will be issued today. Failure to correct the deficiency may result in further civil penalties. An exit interview was held, appeal rights were provided, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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 12/09/2021 03:08 PM - It Cannot Be Edited


Created By: Christina Valerio On 12/09/2021 at 02:15 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: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2021
Section Cited
CCR
87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:
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Licensee stated the fire mashall was scheduled to come to the facility when the fire marshall inspected the CIty Creek Skilled Nursing Facility next door earlier in the year. Licensee had maintainence schedule an inspection with the fire mashall prior to LPA leaving the facility. LPA will be notified of appointment date by POC due date.
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Based on observations, the licensee did not ensure that all fire extinguishers were inspected annually. The last inspection date was observed to be on 08/11/2020.
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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: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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