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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700835
Report Date: 01/29/2025
Date Signed: 01/29/2025 03:05:57 PM

Document Has Been Signed on 01/29/2025 03:05 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: 116DATE:
01/29/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Caleb Summerhays and Katelyn FloresTIME VISIT/
INSPECTION COMPLETED:
03:16 PM
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Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a quarterly visit on 01/30/25, LPA Lee met with administrator Caleb Summerhays and administrator assistant Katelyn Flores and explained the purpose of the visit.

The purpose of today’s visit was to conduct a quarterly inspection. LPA toured the facility, including the lobby, dining area, hallways, resident lounge, and the designated outdoor smoking area. Multiple residents’ rooms were also inspected. Furniture throughout the facility, including those intended for residents’ use, was found to be in good repair. Toxins were inaccessible to residents. The facility's indoor temperature was 73°F. During tour of the facility inspections, LPA did not observe any roaches or pests in the residents' rooms and facility. However, LPA noted a strong urine odor in resident room 106 and a mild urine odor in room 213. LPA also observed a resident in room 206 seeking assistance, and it was learned that the call light in that room was not in good repair. In the kitchen, LPA Lee observed the cooking stove and oven to be covered with grime, grease, and food debris. The sink had a dirty pot and appeared unsanitary. A bag of dirty rags was found on the floor. LPA observed there was a sufficient supply of perishable (2-day) and non-perishable (7-day) food. The carbon monoxide detector in the kitchen was in good repair. LPA reviewed the medications for three residents in (Med Charts 1, 2, and 3) and found no discrepancies. Additionally, LPA reviewed 9 facility staff files, and First Aid/CPR certifications were current.

LPA Lee followed up with the following:

· Facility resident pressure injuries (none at this time)
· Update of Facility staff roles, duties, and responsibilities (document was provided to LPA Lee)
· Pharmacy addition for filling resident prescriptions (Facility is using Omnicare)
· Staff Files (9 staff has current CPR)
· Wander Guard System (observed 8 residents wearing wander guard on wrist)
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/29/2025
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As a result of this quarterly visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies will not be cited during this visit; however, deficiencies will be addressed and cited on complaint control number # 27-AS-20250115102932 and complaint control number # 27-AS-20241126134828.

An exit interview was conducted, and a copy of the LIC 809 reports was provided to administrator.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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