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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700579
Report Date: 09/28/2023
Date Signed: 10/02/2023 09:15:08 AM


Document Has Been Signed on 10/02/2023 09:15 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CHATEAU AT RIVER'S EDGE, THEFACILITY NUMBER:
342700579
ADMINISTRATOR:MUNDAY, PAMELAFACILITY TYPE:
740
ADDRESS:641 FEATURE DRTELEPHONE:
(916) 921-1970
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:143CENSUS: 86DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Chelsea XiongTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 09/28/2023 at 8:30 AM. LPA Martinez met with Chelsea Xiong and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for 26 ambulatory residents and 116 non-ambulatory residents, which 10 may be bedridden. In addition, the facility has an approved hospice waiver for 15. There are currently 86 residents who reside at this facility.

LPA Martinez toured the facility with Karla Rocha on 09/28/2023 at 2:30 PM.

Due to insufficient time, the annual will require a continuation visit. The Department will return at a later date to complete the annual inspection. However, at today's 09/28/2023 annual inspection the following deficiencies were observed:

  1. Nine out ten employees were missing first aid certificates.
  2. Kitchen freezer measured at 10 degrees.
  3. Kitchen refrigerator measured at 47 degrees.
  4. Resident 1 (R1) is on a special diet (Gluten Free) However, facility kitchen staff was unaware of special diet and facility staff reported resident 2 (R2) is also on a glutin free diet. The facility has not implemented a glutin free plan.
  5. Pond/large body of water procedures are being reviewed by LPA Martinez.
As a result of this annual inspection, the following deficiencies can be found on the 9099 D page. In addition, the Department will return at a later date to complete the continuation of this annual visit. An exit interview was conducted, and copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2023 09:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2023
Section Cited
CCR
87411(c)(1)

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87411(c)(1) Personnel Requirements - General: All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...Staff providing care shall receive appropriate training in first aid
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Facility staff agrees to complete first aid training to all staff by POC 10/10/2023. POC will be cleared by visit.
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from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidence by: Based on file review, The Licensee did not ensure 9 out of 10 employees had first aid annual training. This posed a potential health and safety risk to residents in care.
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Type B
10/10/2023
Section Cited
CCR87555(b)(21)

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87555(b)(21)General Food Service Requirements: The following food service requirements shall apply: Freezers of adequate size shall be maintained at a temperature of 0 degrees... and refrigerators of adequate... maximum temperature of 40 degrees F (4 degrees C)...
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Facility staff agrees to conduct temperature checks and regulate freezer and refrigerator temperatures as of today until POC Date. In addition conduct in-service training for all kitchen staff in regards to regulation general food and services requirements. By POC Date 10/10/2023.
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This requirement was not met as evidence by: Based on inspection, the Licensee did not ensure temperature measures at 0 and 40 degrees. Freezer measured at 10 degrees and refrigerator measured at 47 degrees. This posed a potential health & safety risk to residents.
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POC to be cleared by visit.
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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2023 09:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2023
Section Cited
CCR
87464(d)

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87464(d) Basic services facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...This requirement was not met as evidence by:
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Facility staff agrees to complete a special diet audit and implement a glutin free diet plan and procedures by POC date 10/10/2023. POC will be cleared by visit.
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Based on record review R1 and R2 are on glutin free diets, which kitchen staff reported having no knowledge of glutin free diets and do not have a service plan to meet the needs of R1 and R2. This posed a potential health and safety risk to R1 and R2.
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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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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