342700579-7-16-2024-27-AS-SRIN-D7HUMB-20240725154205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700579
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:16:44 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2024 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240327132006

FACILITY NAME:	CHATEAU AT RIVER'S EDGE, THE		FACILITY NUMBER:	342700579
ADMINISTRATOR:	MUNDAY, PAMELA		FACILITY TYPE:	740
ADDRESS:	641 FEATURE DR		TELEPHONE:	(916) 921-1970
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	143	CENSUS: 73	DATE:	07/16/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Marianne Richardson		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Licensee does not ensure facility is in good repair.
Staff do not respond to resident requests for assistance in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Marianne Richardson, and explained the purpose of the visit.

The following has been determined in regards to the aforementioned allegations. The investigation consisted of review of facility maintenance logs, records review of resident files, observations of the facility physical plant, interviews with facility staff, and interviews with residents in care.

Continues on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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 5

Control Number 27-AS-20240327132006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CHATEAU AT RIVER'S EDGE, THE	FACILITY NUMBER: 342700579
	VISIT DATE: 07/16/2024

NARRATIVE

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Continued from LIC 9099

According to an interview with the reporting party (RP), the facility elevator has broken down 12 times. Recently, the two times the elevator broke down, it was down for 10 days. For the individuals on the second and third floors of the building, they were not able to go down to the first floor. The facility would bring up the food to the residents. By the time, the resident received the food, it was cold. If a resident were to call for assistance with Activity of Daily Living (ADL), the resident had to wait 45 minutes to respond too the call. The RP expressed concern of if there was a fire, all residents on the second and third floor would end up dead. RP stated there is not enough man power or time to get residents out safely. In December of 2023, the roof leaked and fell down while the RP and resident was eating lunch. The RP provided pictures of the roof being in disrepair.

On 04/03/2024, LPA Kimberly Viarella observed the facility. LPA observed the main dining room in Assisted Living (AL) was closed as the ceiling is being repaired and other updates were in the process of being completed. According to an interview with the Dining Room Manager, the elevator was repaired on 03/29/24 after being out of order for 8 days. It went down at 3:00 PM on 03/20/24, and came back into operation at 3:20 PM 03/28/24. LPA Viarella learned that Alpha One Ambulance Medical Services keeps an office at the Chateau at River's Edge, in the Independent Living (IL) portion of the facility. They were on call to assist with transporting residents up and down the stairs as requested. During that time, staff received stair chair training so that they were also able to assist residents in moving between floors while the elevator was out of order.

On 04/15/2024, LPA Victoria Brown conducted a complaint investigation for a separate complaint (27-AS-20240411120832) regarding an allegation of staff does not prevent facility roof from leaking. LPA Brown learned the facility secured a contract with Sonray Construction to fix the roof in November of 2023. Due to weather conditions, the construction was delayed. To ensure safety, dining for residents were moved to another area. Resident rooms were not affected. Finding was determined unfounded.

On 05/23/2024, LPA Valerio observed the facility. LPA Valerio observed the dining room and kitchen to be closed off from residents as it was under construction. LPA Valerio also observed the elevator to be in working condition.
Continues on LIC 9099 - C, page 3

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20240327132006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CHATEAU AT RIVER'S EDGE, THE	FACILITY NUMBER: 342700579
	VISIT DATE: 07/16/2024

NARRATIVE

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Continued from Page 2, LIC 9099- C

On 07/09/2024, LPA Valerio observed the facility. LPA Valerio observed the construction to be completed in the dining room and kitchen. The elevator was observed to be in working condition. The elevator has an active permit issued by the Department of Industrial Relations - Division of Occupation Safety & Health. The inspection was on 02/13/24 and the permit expires 02/13/2025.

LPA Valerio reviewed elevator log records. Elevator records show the elevator had a trouble call to TK Elevator 14 times throughout February 2023 to November 2023. The TK Elevator Repair, Test, and Callback Log showed entry dates for 02/13/24, 02/27/24, 02/29/24, 03/08/24, and 03/28/2024. During their hydraulic maintenance task log, it was completed during February 2024.

LPA Valerio interviewed Administrator Marianne, which corroborated statements discussed with LPA Brown and LPA Viarella. Administrator Marianne started as the administrator in January of 2024. When the elevator went down in March, the facility used TK Maintenance, which was the maintenance company used prior to Administrator being brought in. Due to the last occurrence, another elevator company was sought out to service and provide maintenance to the facility elevator. Administrator stated they had round the clock staff and Alpha One to assist residents up and down the stairs. They have 3 chair lifts. Alpha One has a station right at the facility, so they are always here. When it first happened, they sent out two crews to assist us because it was during meal time. The chair operates with the help of two staff. Residents had the option to dine in their room, dine upstairs in the common area on the floor, or dine down stairs. The facility turned the activity room and another common area into dining areas. Meals could occur on the first, second, and third floor of the facility. Restaurant crew was bringing hot plates to room and carrying hot trays up and down all the stairs. They made sure socialization was still happening, people were getting fed, and people were getting what they needed. They also brought programming to each level so residents were not confined to their rooms. Administrator stated there was never a time where someone was stuck up there.

Continues on LIC 9099 - C, Page 4...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20240327132006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CHATEAU AT RIVER'S EDGE, THE	FACILITY NUMBER: 342700579
	VISIT DATE: 07/16/2024

NARRATIVE

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Continues from Page 3, LIC 9099 - C

R1 recalled the incident of when the elevator went down. The staff would assist R1 by taking R1 to the back stairs. R1 stated it was 2 sometimes, maybe 3 staff that helped R1 down the stairs. R1 uses a walker. R1 would go down anytime R1 wanted to go there. It was mostly for meals. R1 said they offered bingo when the elevator was down. They offered to bring meals up to the room. R1 preferred going downstairs because the plates were hotter. When eaten upstairs, they were warm. They were not cold but not extremely hot. Staff would take about 10 - 15 minutes to get to R1's room. R1 stated R1 was never stuck upstairs.

R2 has been a resident since December of 2023. In December, things were different compared to how they are now. In December, staff would take 45 minutes to an hour to respond to R2's call. Currently, staff take 10 - 15 minutes to respond to calls. R2 stated it was due to staff shortage. R2 recalls a time where a staff was shadowing one day and then the next day the staff was on their own. R2 believes that staff need additional training to care for residents, there needs to be better communication between management and residents, and staff/residents need to be trained on emergency evacuations. R2 stated there have been no fire drills since living at the facility. R2 stated the elevator breaks down on a regular basis. Staff brought everything to R2, meals and activities included. According to R2, staff made it work.

R3 stated R3 was never stuck upstairs, is independent, and remembers staff bring meals to the room. R3 stated it took about 20 minutes for staff to respond.

R5 stated on weekends, it takes staff longer to respond, possible due to being short staff. Staff take 30 minutes or longer to respond to calls on weekends compared to right away to 10 minutes on the week days. R5 stated the elevator has always worked, feels safe, and says staff treat them well.

Continues on LIC 9099 - C, Page 5

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20240327132006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CHATEAU AT RIVER'S EDGE, THE	FACILITY NUMBER: 342700579
	VISIT DATE: 07/16/2024

NARRATIVE

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Continued from Page 4, LIC 9099

LPA Valerio interviewed five (5) staff, Staff 1 (S1) - Staff 5 (S5).

S1 works morning shift. S1 says it takes staff about 5 to 10 minutes to respond to resident call. If they are short, they work together to make sure they get to all the residents. S2 stated there is 5 - 6 staff on shift, sometimes 7 staff to directly care for the residents.
S2 typically does immediately to help residents if S2 sees a call. If S2 is busy, S2 will use the walkie talkie to get someone else to respond to the call. S2 takes time with the resident and does not want to rush so they can get what they need. S2 does not recall a time when the elevator went down.
S3 stated response time depends on how many staff are on shift and if the person is available. S3 stated it could take anywhere from one minute, five minutes, to fifteen minutes. S3 stated they use a Tablet aerial system for resident pendant calls to see who is calling and Carestream is used to document ADLs. S4 stated there are times where things are not working, but the facility gets them fixed.
S4 feels there is enough staff on shift to care for the resident. S4 takes less than 5 minutes to answer the call lights. When the elevator broke down, staff brought everything upstairs, including meals.
S5 stated training has been given for emergency evacuation, general orientation, and e-learning. S5 used the "special wheelchair" to get the residents down when the elevators were not working. S5 stated they needed two people to assist and it would not take long because they worked together. S5 answered call lights immediately. S5 stated we have to make sure we answer right away. Just in case they use the restroom or they want to get up, we do not want them to fall. When S5 is busy, S5 uses the radio to call for someone to help. S5 stated there is not a time where staff do not respond right away.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held and a copy of report was given to Executive Director/Administrator Marianne Richardson.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

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