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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700579
Report Date: 01/21/2022
Date Signed: 01/21/2022 01:04:56 PM

Unsubstantiated


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
09/28/2021 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210928072212
FACILITY NAME:CHATEAU AT RIVER'S EDGE, THEFACILITY NUMBER:
342700579
ADMINISTRATOR:MICHAEL TALANIFACILITY TYPE:
740
ADDRESS:641 FEATURE DRTELEPHONE:
(916) 921-1970
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:143CENSUS: 68DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mike TalaniTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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-Facility did not follow resident's care plan -Facility staff are not adequately trained
-Resident sustained fractures while in care
-Facility did not accept resident back after a hospital visit
-Facility did not notify resident's representative in a timely manner of a change in resident's needs for a higher level of care
-Resident's room was not properly cleaned while in care
-Resident was unkempt while in care -facility did not request for an exception to use recliner instead of bed
-Resident sustained a pressure injury while in care
-Facility did not have sufficient staff to meet the residents' needs
INVESTIGATION FINDINGS:
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On 1/21/2022 at 9:15AM, Licensing Program Analyst (LPA) Chris Hopkins arrived at this facility unannounced to conduct a complaint investigation regarding the above allegations. LPA met with Executive Director Mike Talani and explained the purpose of today's visit.

Regarding the allegation of Facility did not follow resident's care plan, the Department found the following: based on interviews and record review it was determined that, Resident 1's (R1) care plan never showed a change in status checks. There was a care plan on 2/17/21 and 4/11/21 and neither of them mentioned status checks every 2 hours for R1. Per R1's responsible party, it was verbally agreed with the Director of Nursing, that R1 would recieve status checks every 2 hours. Staff 1 stated that it was standard practice to "try" and check on residents every 1-2 hours during the night, but that varies on each resident.

Report continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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 6
Control Number 27-AS-20210928072212
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: CHATEAU AT RIVER'S EDGE, THE
FACILITY NUMBER: 342700579
VISIT DATE: 01/21/2022
NARRATIVE
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Regarding the allegation of, resident sustained fractures while in care, the Department found the following: this allegation was investigated by the Department of Social Services Investigative Branch (IB). Based on medical record review and interviews, IB determined that Resident 1 (R1) may have sustained fractures, but CT scans/images couldn’t determine if they were fractures or not. R1’s doctor was interviewed and stated that R1 had three possible acute fractures along her spine, which means based on CT imaging, R1’s doctor could not be certain if what she saw were fractures. And if they were fractures R1’s doctor could not determine the age of these fractures, whether they were new or old. IB has deemed the complaint findings as UNSUBSTANTIATED.

Regarding the allegation of, Facility did not accept resident back after a hospital visit, the Department found the following: based on interviews it was determined that, Kaiser called the facility and spoke with a newly hired LVN Staff 2 (S2), who didn't understand the verbiage so he provided wrong information to Kaiser. Once the Administrator found this out, the Administrator immediately called R1's responsible party to explain the confusion and stated that R1 was able to come back to the facility and S2 called Kaiser back to explain the confusion. By this time R1's responsible party already found another care facility.

Regarding the allegation of Facility did not notify resident's representative in a timely manner of a change in resident's needs for a higher level of care, the Department found the following: based on interviews and record review it was determined that, the change in R1's needs happened when R1 was sent to the hospital for the latest fall. R1's responsible party was notified of this fall. While in care R1 remained at level 1.

Regarding the allegation of Resident's room was not properly cleaned while in care, the Department found the following: based on observation and interview it was determined that, Administrator stated that staff left R1's room exactly the way it was after R1 moved out. 2 different LPA's observed R1's room to be clean.



Regarding the allegation of Resident was unkempt while in care, the Department found the following: based on interview with the Department's Investigative Branch, the Investigator stated that he/she only saw video of R1 at night time. R1 didn't appear to be neglected, dirty, or not cared for. R1 was in his/her pajamas with his/her hair messy, but appropriate for bed time. The investigator did not see any video of R1 during the day.

Report continued on LIC9099-C...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20210928072212
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: CHATEAU AT RIVER'S EDGE, THE
FACILITY NUMBER: 342700579
VISIT DATE: 01/21/2022
NARRATIVE
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Regarding the allegation of Resident sustained a pressure injury while in care, the Department found the following: based on interview and record review it was determined that, R1 did have redness on the coccyx and a small open area (1cm x 1cm) on the buttocks, which was resolved by the physician and Kaiser home health. Care staff noticed this before it got bad. Per the Administrator, R1 was given the option for phyiscal therapy and activities but R1 refused and wanted to stay in his/her recliner.

Regarding the allegation of Facility did not have sufficient staff to meet the residents' needs, the Department found the following: based on record review and interview it was determined that, the facility had at least 3 caregivers on shift during the night, which falls in line with Title 22 regulations.

Regarding the allegation of facility did not request for an exception to use recliner instead of bed, the Department found the following: based on interview and record review it was determined that, R1 was not to put to bed in the recliner, it was R1's choice to stay in recliner. Per Administrator night shift would make their rounds and R1 always wanted to stay up a little longer and watch tv. R1 would normally get out of the recliner and go to bed. Per R1's care plan, R1 was able to transfer independently.

Regarding the allegation of Facility staff are not adequately trained, the Department found the following: based on record review it was determined that, care staff have all updated training. S1 admitted to making the mistake of not visually seeing R1, and S1 knows he/she was wrong and owned up to it. S1 does have up to date training.

Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator Mike Talani. A copy of this report was left with Administrator upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/28/2021 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210928072212

FACILITY NAME:CHATEAU AT RIVER'S EDGE, THEFACILITY NUMBER:
342700579
ADMINISTRATOR:MICHAEL TALANIFACILITY TYPE:
740
ADDRESS:641 FEATURE DRTELEPHONE:
(916) 921-1970
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:143CENSUS: 68DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mike TalaniTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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-Resident was left on the floor unattended for an extended period of time
INVESTIGATION FINDINGS:
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On 1/21/2022 at 9:15AM, Licensing Program Analyst (LPA) Chris Hopkins arrived at this facility unannounced to conduct a complaint investigation regarding the above allegations. LPA met with Executive Director Mike Talani and explained the purpose of today's visit.

Regarding the allegation of, resident was left on the floor unattended for an extended period of time, the Department found the following: this allegation was investigated by the Department of Social Services Investigative Branch (IB). Based on interviews and video footage review, IB determined that Resident 1 (R1) was left on the floor unattended for an extended period of time. At 8:12pm R1 was sitting in his/her reclining chair, and a caregiver came in the room putting the footrest up and a blanket over R1. At 9:58pm R1 tries to get up but cant due to the footrest being up. R1 then slides down the recliner tipping it forward, and R1 falls on to the ground...

Report Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20210928072212
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: CHATEAU AT RIVER'S EDGE, THE
FACILITY NUMBER: 342700579
VISIT DATE: 01/21/2022
NARRATIVE
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R1 lays on the ground until the next morning. It was noted that a caregiver came in R1’s room some time between 5am and 6am to drop off laundry but didn’t actually go all the way in R1’s room so the caregiver never saw R1 on the ground. At 8:02am a med tech came in R1’s room and saw R1 was laying on the ground, this is when staff called the paramedics. IB noted that care staff stated that the frequency of resident checks varies throughout the night, however staff try to check on residents every 2 hours unless their care plan states otherwise. Based on interviews and video footage review, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20210928072212
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: CHATEAU AT RIVER'S EDGE, THE
FACILITY NUMBER: 342700579
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2022
Section Cited
CCR
87464(f)(1)
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Basic Services 87464 (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living...without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by:
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Administrator has agreed to provide LPA with documented trainings by POC Due Date.
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Based on interviews and video footage review, the licensee did not ensure care and supervision was being provided to R1, as evidenced by R1 being left on the ground overnight.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6