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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 05/14/2026
Date Signed: 05/14/2026 02:46:25 PM

Document Has Been Signed on 05/14/2026 02:46 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/
DIRECTOR:		CALEB SUMMERHAYSFACILITY TYPE:
740
ADDRESS:6254 66TH AVENUETELEPHONE:
(916) 393-2324
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 121CENSUS: DATE:
05/14/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:26 PM
MET WITH:Katelyn FloresTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
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On 05/14/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a case management visit regarding an incident report received by the Department. LPA Lee met with Health Services Director (HSD) Katelyn Flores and explained the purpose of the visit.

On 04/09/2026, the Department received an LIC 624 Incident Report regarding an incident that occurred on 04/07/2026 involving Resident 1 (R1)’s medication. LPA Lee reviewed the incident report and learned that R1’s Hydrocodone medication, which had been delivered on 04/02/2026, was missing from the narcotic drawer. The facility conducted an internal investigation regarding the missing medication. Per HSD Flores, the medication was delivered from the pharmacy and hand delivered to Medtech, who signed and acknowledged receipt of the medication. HSD Flores stated that two (2) Medtechs then observed and counted the quantity of the medication and logged it into the medication inventory log. According to the facility’s investigation, there was no documentation indicating that the medication had been destroyed or signed out to family members or physicians.

Per the facility’s investigation, it was determined that Staff 1 (S1) may have taken the medication. It was further learned that S1 may have ripped and attempted to shred the medication inventory log and narcotic count sheet. The incident was reported to law enforcement and the resident’s physician, and the police report number was provided to the physician. Per HSD Flores, narcotic medications are inventoried every shift (three times daily).

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CITY CREEK ASSISTED LIVING
FACILITY NUMBER: 342700835
VISIT DATE: 05/14/2026
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However, the facility was unaware that the medication was missing because the medication inventory log and narcotic count sheets were also removed and destroyed. The issue was only discovered when another Med-Tech questioned HSD Flores regarding the medication, as the staff member had been present when the medication was delivered on 04/02/2026. This resulted in a lapse in the facility’s narcotic medication auditing process.

As a result of this case management visit, the facility was found to be out of compliance with Title 22 regulations. The deficiency is cited on the attached LIC 809-D page. An exit interview was conducted with HSD Flores and copies of the LIC 809 report, LIC 809-D page, and Appeal Rights were provided to the facility representative. Failure to correct the deficiency may result in civil penalties.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2026 02:46 PM - It Cannot Be Edited


Created By: Pang Lee On 05/14/2026 at 02:26 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: 05/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2026
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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The facility will implement having an electronic narcotic inventory so those medications documents cannot be destroyed and be accounted for. The facility will implement having an electronic narcotic inventory so those medications
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Based on record review, the licensee did not comply with the section cited above. R1’s Hydrocodone medication went missing and couldn’t be located. This poses an immediate health, safety or personal rights risk to persons in care.
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documents cannot be destroyed and be accounted for. Until the electronics gets implanted the medtechs will provide HSD Flores copies of the CSMDR. A statement of acknowledgement will be provided to LPA Lee by 05/22/2026 at the end of day.

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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
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