342700835-11-15-2021-27-AS-SRIN-C8ZQ2J-20211122104710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 11/15/2021
Date Signed: 11/15/2021 04:55:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2021 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210927154924

FACILITY NAME:	CITY CREEK ASSISTED LIVING		FACILITY NUMBER:	342700835
ADMINISTRATOR:	LITTERER, KEVIN		FACILITY TYPE:	740
ADDRESS:	6254 66TH AVENUE		TELEPHONE:	(916) 599-7033
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	121	CENSUS: 104	DATE:	11/15/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Caleb Summerhays		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Residents are not getting their medications as ordered by physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. 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.

The investigation was conducted by LPA Valerio. The investigation consisted of interviews with residents, interviews with staff, and review of resident files.

The Department has determined the following as it relates to the allegations: Residents are not getting their medication as ordered by physician.

Continued on LIC 9099 - C...
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20210927154924

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/15/2021

NARRATIVE

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...Continued from LIC 9099

On 09/28/21, LPA Valerio interviewed Staff 1 (S1). When asked if S1 knew if any residents are not getting their medication as ordered by a physician, S1 confirmed that S1 knew of an incident that occurred on 09/25/21. S1 stated that a medication technician called out from work, which left the facility short staff. S1 stated there were residents in hallway 3 that did not receive their medications. S1 admitted that S1 did not send an incident report to licensing. On 09/28/21, LPA Valerio interviewed Staff 2 (S2). Staff 2 reported that prior to S2 being employed with City Creek Assisted Living, the facility had many issues with pharmacies bringing medications to the facility. S2 reported that since being hired, S2 did not observe residents not getting their medications due to staff forgetting to give the medication. S2 stated if a resident does not get their medications, "it is simply due to the pharmacy not having it."

On 10/14/21, LPA Valerio interviewed two residents (R1 and R4). R1 stated, "In the last three weeks, I have not had my medications three times. I go to try to get my medications and the nurses are nowhere to be found. Once I finally find a staff, they say that the medications are locked up and I can't get it. I wait hours until I finally get the medications." R4 informed LPA that R4 did not receive medications from staff and did not know the reason for it.

LPA Valerio reviewed resident files for Resident 1 (R1) - Resident 4 (R4). LPA Valerio observed R1 did not receive a controlled medication on 08/13/21 due to staff forgetting to give it. Resident 2 (R2) file was reviewed. R2 did not receive a medication order on 08/02/21 - 08/05/2021 due to waiting on pharmacy. Resident 3 (R3) file was reviewed. R3 did not receive three orders of medication for the entire month of August due to conflicting reasons: Waiting on Pharmacy, Resident Refused, and Withheld per DR/RN Orders. Resident 4 (R4) file was reviewed. R4 did not receive a medication on 10/04/21 - 10/16/21. On 10/12/21 - 10/16/21, R4 received the medication at 8:00 AM and at 12:00 PM. However, at 4:00 PM on 10/12/21 - 10/16/21, the reason for not receiving the medication was the facility was waiting on the pharmacy.

Based on medical record review, interview, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was provided to facility staff Caleb Summerhays.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210927154924

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 12/01/2021 Section Cited CCR 87645(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (5)The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by:	1 2 3 4 5 6 7	The licensee agrees to: provide incidental and medical training and ordering medication to staff by POC date 12/01/2021.
	8 9 10 11 12 13 14	Based on record and interviews, the licensee did not ensure R1, R2, R3, and R4 were receiving their medication as order by their physician, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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