075600194-4-13-2021-15-AS-KHOS-C2VHWE-20210510063325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600194
Report Date: 04/13/2021
Date Signed: 04/13/2021 10:45:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2020 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200508084825

FACILITY NAME:	CHATEAU III		FACILITY NUMBER:	075600194
ADMINISTRATOR:	TRACEY INGLEMAN		FACILITY TYPE:	740
ADDRESS:	175 CLEAVELAND ROAD		TELEPHONE:	(925) 935-1001
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	175	CENSUS: 120	DATE:	04/13/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Tracey Ingleman, Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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-Questionable death.
-Staff failed to contact authorized representative(s) in a timely manner about residents change of medical condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Executive Director (ED) Tracey Ingleman to deliver findings on the above allegations. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference.

On 5/11/20, the Department's Investigation Branch (IB) accepted an assignment to conduct a full investigation into these allegations. The allegation of questionable death pertained to R1's 4/20/20 passing. It was alleged that the facility contributed to R1's death by denying R1 proper medical treatment prior to R1 moving out of the facility on 4/14/20.

See LIC9099-C for continuation of report.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200508084825

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CHATEAU III	FACILITY NUMBER: 075600194
	VISIT DATE: 04/13/2021

NARRATIVE

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During the course of IB's investigation, there was insufficient evidence to substantiate that the facility contributed to the death of R1. R1 was a resident in the assisted living wing of the facility and received dressing/showering assistance, medication management, and could leave the facility unattended. Furthermore, R1 and R1's doctor and responsible party had a consultation on the day prior to R1's departure from the facility (4/13/20). R1's doctor noted R1 was asymptomatic and fully engaged in making decisions about R1's Physician Orders for Life-Sustaining Treatment (POLST). Once approval was received by the Contra Costa Public Health Department, R1 authorized departure from the facility. As documented, R1 left on R1's own accord from the facility.

It was also alleged that staff failed to contact R1's responsible party in a timely manner regarding R1's change in medical condition. Based on statements made by facility staff, medical records, and facility documents, R1 was provided proper care and, in instances where issues arose, the facility notified
the family properly. Alerts, notifications, care report notes, and conversations with family
about changes in R1's health were well documented. In the days leading to R1's
departure, facility staff actively worked with the family and communicated all changes
regarding R1.

This agency has investigated the complaint allegations. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

LIC9099 (FAS) - (06/04)

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