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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700835
Report Date: 12/13/2021
Date Signed: 12/13/2021 05:35:36 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
10/11/2021 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211011125942
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: 101DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Staff are not following the resident's care plan
Facility is understaffed
Facility is not screening visitors
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. Facility staff confirmed zero residents and zero staff have displayed any signs or symptoms of COVID-19 in the last 10 days.

The investigation was conducted by LPA Valerio. The investigation consisted of interviews with residents, interviews with staff, review of resident files, review of medical records, and observation of the facility.

The Department has determined the following as it relates to the allegations: Staff are not following the resident's care plan, facility is understaffed, and facility is not screening visitors

Continues on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 7
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
10/11/2021 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20211011125942

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: 101DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caleb SummerhaysTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Resident is not receiving food or water
Resident has lost significant weight since admission
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. Facility staff confirmed zero residents and zero staff have displayed any signs or symptoms of COVID-19 in the last 10 days.

The investigation was conducted by LPA Valerio. The investigation consisted of interviews with residents, interviews with staff, review of resident files, review of medical records, and observation of the facility.

The Department has determined the following as it relates to the allegations: Resident is not receiving food or water and Resident has lost significant weight since admission

Continues on LIC 9099-C..
Page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20211011125942
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: 12/13/2021
NARRATIVE
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LPA Valerio interviewed resident 1 (R1), Resident 2 (R2), and Resident 3 (R3) regarding meals at the facility. R1 stated, "There is always enough food. Sometimes not on time. Sometimes the food is not worth eating."  R2 stated, "Food is good." R3 stated, "I like the meals here." According to record review for R1-R3 for September - October 2021, R1 and R2 did not refused any meals, while R3 refused meals 4 times, which was documented in the charting notes.

LPA interviewed staff (S1 - S5) regarding documentation on food and water intake. S1 does not believe that a resident is not receiving food or water. S1 stated, "patients have rights. Residents can refuse. Medication Technicians and caregivers should be documenting. I am not sure if they do." S2 stated the facility only documents food refusals. Residential aids inform medication technicians if a resident refuses to go to the dining hall. S5 would make sure residents in her hall would get something to eat. S5 could only speak for S5's assigned hall and does not know about the other halls. S5 would inform the cafeteria staff to bring a food tray to the room if a resident was not feeling well to eat.

LPA Valerio interviewed staff regarding weight documentation. According to S1, residents are weighed monthly. If there is a 5 pounds difference, the staff will notify others. S1 stated, "If a resident refuses to be weighed, what can we do." S3 informed LPA that Residential Aids are supposed to check the weight monthly. Due to the facility being short staff, the staff are too busy to do it. S4 stated, "we check some resident's weight but not all residents. A lot of residents refuse it."

According to facility documentation, the weight of each resident was only captured on the LIC 602 Physician's Report. R1 did not have any record of weight. R2 did not have updated information regarding weight. R3 had two LIC 602's on file. The first LIC 602 was from the Skilled Nursing Facility in 2020 and the second LIC 602 was from City Creek Assisted Living in 2021. LPA observed there was a difference in weight in the amount of 41 pounds for R3 while at the Skilled Nursing Facility.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED.  Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.  Exit interview was held and a copy of report was given to Program Director Caleb Summerhays.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20211011125942
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: 12/13/2021
NARRATIVE
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...Continued from LIC 9099

Resident 1 (R1) - Resident 3 (R3) were interviewed by LPA Valerio. R1 stated resident has not received her medications while living here. R2 stated R2 always gets medications, sometimes four times per day. R3 stated staff give medications daily. According to records review for R1, R1 did not receive medications multiple times during September - October 2021. According to records review for August 2021 - October 2021, R2 had a total of 210 missed medication doses due to waiting on pharmacy. According to records review for R3, R3 had 233 missed medication doses due to waiting on pharmacy. On 07/16/2021, R3's physician ordered the facility to use a APAP machine anytime R3 sleeps. Kaiser medical records show that the APAP machine shows 0 usage from July 2021 - October 2021. It was later discovered by family that the machine was under R3's bed untouched and unopened.

LPA Valerio interviewed Staff 1 (S1) - Staff 5 (S5) regarding facility staffing. All staff stated the facility is short staff. S1 stated, "no one wants to work. What can we do if  we can't get people to start." S2 stated, "Most of the time we are, it would be nice to have more [staff]." S3 stated, "We are getting more residents but we do not have staff. The residents are not getting the care they need. We have over 100 residents. We only have 2 residential aids that are supposed to look over the resident[s]." S4 stated, "On AM shift, we were never really short but I know PM shift was sort all the time. It was either one person or two persons for all three halls ." S5 stated while working a double shift, "they need it, so I help them out."

LPA Valerio received voicemail regarding the facility on two occasions. On 10/17/2021 at 7:37AM, LPA Valerio received a voicemail stating, "Hi Christina. I am calling from City Creek Assisted Living to let you know it is happening today again today. We are short on med techs today and we are not getting our medications. Please. We need help." On 10/18/2021 at 2:04PM, LPA Valerio received a voicemail stating, "This is…following up on our conversation. This weekend was quite short. They were supposed to get help but I guess they loss it and I found that interesting. Call me back, thank you…"

LPA Valerio reviewed the staff schedule for September - October 2021. The facility was observed to be short staffed on 29 shifts for Medication Technicians and Residential Aids.

Continues on LIC 9099 - C page 3...
Page 2 of 3
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 27-AS-20211011125942
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: 12/13/2021
NARRATIVE
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Continued from Page 2

The facility has a receptionist who is to screen all visitors. S1 stated, "Day shift receptionist is on schedule on Monday -Friday. Another receptionist is on schedule for Saturday- Sunday from 8:00 AM to 5:00 PM. For PM shift, there is no receptionist. Front entrance doors should be locked after 5:00 PM. For someone to get in they have to schedule an appointment or ring the door bell and have to wait until staff come to the door. LPA reviewed the visitor screening log for September - October 2021. LPA observed screening logs for every day except 09/11/2021 - 09/13/2021. On 10/14/2021, LPA Valerio was screened for COVID-19 symptoms. On 11/15/2021, LPA was screened for COVID-19 symptoms. On 11/15/2021, LPA observed an unidentified man walk through the front door and walk past the receptionist desk. Staff were assisting residents and setting up an activity. Staff did not notice man walking through the facility until 5 minutes later. On 12/09/2021, LPA Valerio was screened for COVID-19 symptoms. On 12/11/2021, LPA Valerio was not screened for COVID-19 symptoms. According to an interview with a responsible party for a resident, the responsible party can come at night time and walk straight to resident's room.

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.











Page 3 of 3.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20211011125942
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: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2022
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed...
(2) The licensee shall provide assistance in meeting necessary medical and dental needs...This requirement was not met as evidenced by:
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The licensee stated during weekly meeting with the medication technicians, a training will be held regarding understanding resident's care plan and documenting on resident's progress and care. Licensee to send LPA Valerio in-service sign in sheet by POC due date.
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Based on record review of three residents, the facility did not ensure to follow the care plan. Resident 1 and Resident 2 had missed medications dosages. Resident 3 had missed medication doses and was not given the APAP machine to use while sleeping. This poses an potential health and safety risk to residents in care.
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Type B
01/13/2022
Section Cited
CCR
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87158 Capacity (b)The number of persons that the facility is licensed to admit shall be determined on the basis of the application review by the licensing agency which shall consider:(4) Number of available staff to meet the care needs of the residents. This requirement was not met as evidenced by:
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The licensee stated the facility has hired 8 additional employees and will continue to fill more positions. Licensee will ensure adequate staffing will be on shift to meet the needs of the residents in care.
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Based on interviews, record review, and observations, the licensee did not ensure the facility had adequate number of staff to meet the needs of the residents, which resulted in R1, R2, and R3 not receiving basic services as agreed upon admission. This poses a potential 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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20211011125942
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: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful ...This requirement was not met as evidenced by:
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The licensee stated they have hired a receptionist for evening time. The licensee will include a training for screening for all staff by POC due date.
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Based on observations, the licensee did not ensure an unidentified man and LPA were screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility, wich poses an immediate heath and safety risk to residents 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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7