342700243-12-16-2021-25-AS-KHOS-C9SLBP-20211217073701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700243
Report Date: 12/10/2021
Date Signed: 12/16/2021 03:59:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2021 and conducted by Evaluator Melissa Lusby

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210601125258

FACILITY NAME:	CHAUPPETTE ASSISTED LIVING LLC		FACILITY NUMBER:	342700243
ADMINISTRATOR:	CHAUPPETTE, SHEREE		FACILITY TYPE:	740
ADDRESS:	6813 MARINVALE DRIVE		TELEPHONE:	(916) 560-8708
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	6	CENSUS: 5	DATE:	12/10/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lee Chauppette		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff left resident in a soiled diaper for a long period of time
Facility illegally evicted resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Lusby and LPA Bains arrived on Thursday December 16, 2021 to deliver an amended report regarding the above allegations. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

Throught the course of the investigation, LPA interviewed the following: staff and hospice personnel. LPA reviewed the following documents: progress notes, Medication Administration Record, eviction notice, hospital discharge paperwork and unusual incident reports.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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 2

Control Number 25-AS-20210601125258

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHAUPPETTE ASSISTED LIVING LLC	FACILITY NUMBER: 342700243
	VISIT DATE: 12/10/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the documents reviewed and the interviews conducted, LPA learned that R1 developed a fungal rash which was treated by a prescription cream. This was not due to neglect of incontinence care. Staff interviews conducted revealed that R1's care plan appropriately addresses her incontinence needs. At times, R1 has behaviors and will not allow staff to provide routine care. Additionally, hospice staff interviewed acknowledged that there were no concerns regarding her incontinence care at the facility.

LPA reviewed the eviction notice served to the resident and POA. Additionally, the Department conducted a case management visit on 7/13/2021 where the eviction notice was discussed with the facility. The eviction letter did not contain the required wording, which made the eviction invalid. While an unlawful eviction notice was served to the resident, Resident is still resides at the facility.

The Department has determined that the above allegations are unsubstantiated. A finding that the complaint allegations are UNSUBSTANTIATED means that although the
allegations may have happened or is valid, there is not a preponderance of the evidence
to prove that the alleged violations occurred.

Exit interview conducted. A copy this report was left at the facility. Appeal rights were given.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Melissa Lusby	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2