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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 10/25/2023
Date Signed: 10/25/2023 03:59:39 PM

Document Has Been Signed on 10/25/2023 03:59 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: DATE:
10/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/25/2023, at 1:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at the facility unannounced to conduct a case management regarding a discovery during a complaint investigation regarding the allegation from 27-AS-20230130141811. LPAs met with Administrator Caleb Summerhays and stated the purpose of this visit.

LPAs Bilger and Villanueva interviewed staff members and reviewed Resident_4’s (R4’s) files, including resident charting notes, resident care plans home health notes, activity of daily living (ADL) notes, and resident physician orders.

Based on record review, R4 was assessed with stage 3 pressure wound on the coccyx area by home health agency on 6/7/23. Based on interview with S1 on 8/30/23, facility did not submit an exception for prohibited health condition regarding R4's condition to the Department once R4 was assessed with stage 3 pressure wound.

Per California Code of Regulations (Title 22, Division 6, Chapter 8) citations for deficiencies can be found on the LIC 809 -D.

An exit interview was held with administrator Caleb Summerhays, and a copy of this report and the appeal rights were provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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 10/25/2023 03:59 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/25/2023 at 01:56 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CITY CREEK ASSISTED LIVING
FACILITY NUMBER: 342700835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
87615(a)(1)

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87615 (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
This was not met as evidenced by:
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Licensee to review the regulation on prohibited health condition and submit a statement of understanding of this regulation. to the Department by POC due date.
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Based on interviews and record reviews, the licensee retained a resident with a stage 3 pressure wound without obtaining an exception from the Department. This posed a potential health and safety risk to the resident 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:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023


LIC809 (FAS) - (06/04)
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