Inspection Reports for
City Creek Assisted Living

The facility was generally clean, odor-free, and in good repair with proper safety measures in place. However, deficiencies were found related to medication storage and staff training documentation.

The complaint investigation was triggered by allegations that facility staff did not assist a resident with medical appointments leading to death and failed to inform the resident's responsible party about a change in condition. The first allegation was found unsubstantiated, while the second was substantiated.

The investigation found the allegation that staff did not assist the resident with medical appointments resulting in death to be unsubstantiated. However, the allegation that staff failed to inform the resident's responsible party about the resident's change of condition was substantiated, with deficiencies cited related to failure to notify and document changes in condition.

The visit was triggered by a complaint investigation control number 27-AS-20241118154836. The complaint was substantiated as the facility failed to follow protocol when a resident missed three dialysis appointments and did not seek timely medical attention.

The facility failed to seek timely medical attention for a resident who missed three scheduled dialysis treatments, violating California Code of Regulations, Title 22, and California Health and Safety Code. This posed an immediate risk to the resident's health and safety.

The complaint investigation was triggered by allegations received on 03/24/2025. One allegation was substantiated regarding failure to notify a resident of visitors. Other allegations about resident participation in care planning and facility odors were unsubstantiated.

One allegation regarding staff not allowing a visitor to see a resident was substantiated due to failure to notify the resident of visitors, violating the Admission Agreement and Plan of Operation. The allegation that staff did not allow resident participation in care planning was unsubstantiated. The allegation regarding odors from incontinence was also unsubstantiated after observations and interviews.

The complaint investigation was substantiated for the allegation that facility staff did not ensure the facility was kept in clean sanitary conditions at all times. The allegation that staff did not ensure the facility was kept free of insects was unsubstantiated.

The allegation that the facility was not kept in clean and sanitary conditions was substantiated due to unsanitary kitchen conditions posing health risks. The allegation that the facility was not kept free of insects was unsubstantiated based on interviews, observations, and pest control records.

The complaint investigation was substantiated. Allegations included failure to respond to call lights, inadequate incontinence care, and improper management of scabies. Evidence included resident and staff interviews, observations of malfunctioning call lights, urine odors, and failure to isolate residents with scabies or notify public health.

The investigation substantiated the complaints, finding that staff did not respond timely to call lights due to an outdated system, incontinence care needs were not adequately met with evidence of urine odors in resident rooms, and scabies cases were not properly managed with residents not isolated and delayed follow-up with physicians.

The complaint was substantiated based on interviews, observations, and records review. Facility staff failed to provide adequate food quality and follow special dietary orders. Unsanitary kitchen conditions and improper food storage were also documented.

The investigation substantiated the complaint that the facility staff did not provide good quality food, including inadequate portion sizes, food served cold, and failure to meet special dietary needs. Unsanitary kitchen conditions and improper food storage practices were also observed.

The complaint alleging staff violated residents' privacy by posting videos on social media was substantiated. Disciplinary action included termination of the involved staff member.

The complaint was substantiated. The investigation found that staff posted videos/photos of residents on social media revealing their identities and personal behaviors, posing an immediate health and safety risk.

The complaint investigation was triggered by allegations received on 07/26/2024. The allegations included staff not assisting residents with medical care, not addressing a scabies outbreak, and not ensuring assistive equipment needs were met. The investigation found two allegations unsubstantiated and one substantiated.

Two allegations were found unsubstantiated after review of records and interviews with residents and staff. One allegation regarding assistive equipment needs was substantiated due to equipment not being in good repair, posing a potential health and safety risk.

The complaint was substantiated based on interviews with six residents, observations of delayed assistance with toileting and incontinence care, and review of facility records showing inconsistent shower schedules and strong urine odors in resident rooms.

The investigation substantiated the allegations that staff failed to assist residents with ADLs and delayed response to call lights. Observations showed residents waited 37 to 40 minutes for assistance, and some residents did not receive showers as scheduled. Strong urine odors were noted in resident rooms, indicating inadequate care.

The facility was generally clean and well-maintained but was found not free of odor, with strong urine odor observed in resident rooms #213 and #110. Medication administration records, resident and staff files were reviewed and found complete. The facility was not in compliance with Title 22 regulations due to odor issues related to managed incontinence.

The complaint investigation was triggered by allegations that facility staff did not report a fall to family, did not assist in feeding, and did not provide medications on time. The fall allegation was unsubstantiated. The feeding and medication allegations were substantiated based on interviews, record reviews, and medication administration records.

The allegation that staff did not report a fall to family was unsubstantiated. However, allegations that staff did not assist in feeding and did not provide medications on time were substantiated, with deficiencies cited related to medication administration and feeding assistance.

The complaint was substantiated. Allegations included failure to provide incident reports to the resident’s authorized representative and failure to dispense medication as prescribed. Investigations included interviews with staff and review of records. The resident refused interviews. Findings confirmed the allegations.

The investigation substantiated both allegations. The facility failed to provide a written incident report to the resident’s responsible party after two falls resulting in hospitalization. The facility also failed to hold the resident’s blood thinner medication as prescribed for dental procedures, posing health and safety risks.

The complaint was substantiated. The allegation was that staff did not ensure residents received their medications as needed. Interviews with staff and residents, and record reviews showed lack of documentation of medication administration. Six out of nine residents stated they were not getting their medications from facility staff.

The investigation found that staff did not properly document medication administration, making it unclear if residents received their medications. Interviews with residents and staff, along with record reviews, substantiated the allegation.

The complaint was substantiated based on records review, staff interviews, and observations. The facility failed to obtain required building permits for alterations. The facility was directed to submit permits and plans to the Sacramento County Building Department and Metro Fire. The facility later removed the unpermitted structure.

The allegation was substantiated. The facility removed a sophet wall and receptionist desk and added a structured wall without obtaining the required building permits. The facility later removed the added structure wall after deciding not to pay permit fees. This posed a potential health, safety, or personal rights risk to persons in care.

The facility has had multiple citations since re-licensing in 2021, including 16 Type A and 8 Type B citations. Key concerns included medication violations such as insulin not being administered by skilled professionals, resident pressure injuries, and the need for updated staff roles and training.

The complaint investigation was substantiated. The allegation was that a resident sustained a pressure injury while in care. The licensee failed to demonstrate adequate and timely monitoring and care of the pressure wound, leading to worsening of the wound.

The investigation found that the licensee did not provide adequate and timely care and monitoring of Resident 4's pressure wound, which worsened from an open sore to a stage 3 pressure wound. The allegations were substantiated and an immediate civil penalty was issued due to repeat violation.

The visit was triggered by a complaint investigation regarding allegation 27-AS-20230130141811. The complaint was substantiated based on the finding that the facility retained a resident with a prohibited health condition without submitting an exception.

The facility retained a resident with a stage 3 pressure wound without obtaining the required exception from the Department, posing a potential health and safety risk. Licensing Program Analysts reviewed records and interviewed staff to confirm this violation.

The investigation found that staff inappropriately assisted a resident with self-administration of blood pressure medication without proper vital sign monitoring, posing a potential health and safety risk. An immediate civil penalty was issued due to repeat violations.

The complaint was substantiated regarding failure to ensure the facility alarm system was in place, allowing a dementia resident to leave unnoticed. Other allegations were unsubstantiated or unfounded based on evidence collected.

The investigation substantiated that staff failed to ensure the facility alarm system was in place, resulting in a resident leaving unnoticed. Other allegations including failure to follow doctors' orders were unsubstantiated. Additional allegations about feeding, medical assessments, dental hygiene, bedding, and facility temperature were found to be unfounded with no deficiencies cited.

The inspection found that a resident was not assisted with self-administration of medication on various dates and medications were not consistently given as ordered during December 2022. Additionally, there was no plan in place to address medications unavailable due to untimely pharmacy response.

The complaint was substantiated based on medical record reviews and interviews, including with the attending Medical Doctor, confirming Resident 1 was left unattended for close to eight hours resulting in injuries. A civil penalty of $500 was issued related to the violation.

The investigation substantiated that Resident 1 sustained multiple injuries consistent with a fall and being left unattended for an extended period due to inadequate staff care and supervision. The facility failed to ensure regular resident checks, resulting in a violation of basic services requirements.

The complaint investigation was substantiated for failure to notify family or CCL of incidents and neglect causing a resident to develop an ulcer wound. The allegation that the facility did not follow physician's orders was unfounded.

The investigation substantiated that the facility failed to notify family and CCL of a resident's pressure ulcer wound and neglected the resident causing the wound. The allegation that the facility did not follow physician's orders was found to be unfounded.

The complaint involved possible neglect related to Resident 1 who had a seizure on 10/18/2022. The incident was not reported to Community Care Licensing as required. The complaint was substantiated based on investigation findings.

The facility failed to report a serious injury incident to Community Care Licensing within the required timeframe and had a designated person in charge who was fingerprint cleared but not associated with the facility. Additionally, staff failed to maintain required criminal record clearance and first aid certification.

The complaint investigation was substantiated. Allegations included failure to provide prescribed medications, failure to transport a resident to the VA hospital, provision of inappropriate medical supplies, and unmet resident needs. The investigation included interviews with residents and staff and review of records. The findings confirmed these issues and cited relevant California Code of Regulations sections.

The investigation substantiated the allegations that residents did not receive medications as prescribed due to staffing and scheduling issues, transportation to the VA hospital was not provided despite resident requests, inappropriate syringe sizes were used for insulin administration, and residents confined to wheelchairs were not assisted in a timely manner. These issues pose immediate health and safety risks.

The visit was triggered by a complaint incident report about a resident leaving the facility unassisted. The complaint was substantiated as deficiencies were found.

The licensee failed to ensure that the resident did not leave the facility unassisted, posing an immediate health and safety risk. Deficiencies were cited related to basic services and supervision.

The complaint investigation was substantiated. Allegations included failure to provide medications as prescribed, insufficient staffing, unskilled staff administering insulin, and unmet resident needs. Evidence included staff and resident interviews and record reviews confirming these issues.

The investigation substantiated all allegations, finding residents missed medication doses due to staffing shortages and scheduling issues, untrained staff administered insulin injections, and residents confined to wheelchairs were not attended to timely. These issues pose immediate health and safety risks and violate Title 22 regulations.

The complaint investigation was initiated based on allegations that staff were not following resident care plans, the facility was understaffed, and visitor screening was inadequate. The investigation included interviews, record reviews, and observations. Some allegations about residents not receiving food or water and weight loss were found unsubstantiated.

The investigation substantiated that the facility failed to follow resident care plans, was understaffed, and did not consistently screen visitors for COVID-19 symptoms. Some allegations related to residents not receiving food or water and weight loss were unsubstantiated due to insufficient evidence.

The inspection found that the facility did not ensure all fire extinguishers were inspected annually, with the last inspection dated 08/11/2020. A $500 civil penalty was assessed for this deficiency.

The visit was triggered by complaint investigation 27-AS-20210927154924. The complaint was substantiated as deficiencies were cited regarding medication error reporting and resident record keeping.

Deficiencies were found related to failure to report medication errors and incomplete centrally stored medication logs for a resident, posing potential health and safety risks.

The complaint was substantiated. The investigation included interviews with staff and residents, and review of resident files. The main allegation was that residents were not getting their medications as ordered by a physician.

The investigation found that residents R1, R2, R3, and R4 did not receive medications as ordered due to staff forgetting, pharmacy delays, and other reasons. The allegations were substantiated based on interviews, medical record reviews, and staff statements.

The licensee failed to ensure that Resident 1 did not leave the facility unassisted, posing an immediate health and safety risk. Deficiencies were cited related to basic services and supervision requirements.

The facility was found to be in good repair with hand sanitizers in each hallway. However, deficiencies were observed related to failure to notify Community Care Licensing of the administrator's resignation and failure to submit an updated LIC 308 form, posing an immediate health and safety risk.

The complaint investigation was triggered by an allegation of illegal eviction. The allegation was substantiated based on interviews and record review. The facility did not provide proper eviction notices to Resident 1 and Resident 2, and failed to follow required procedures. The investigation included interviews with the administrator, discharge planner, and attempts to interview a doctor. The preponderance of evidence standard was met.

The investigation substantiated that the facility did not follow proper eviction procedures for one of two residents, posing a potential health and safety risk. The facility failed to ensure required eviction notices and documentation were provided as per California regulations.