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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700579
Report Date: 04/03/2025
Date Signed: 04/03/2025 11:18:08 AM

Document Has Been Signed on 04/03/2025 11:18 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CHATEAU AT RIVER'S EDGE, THEFACILITY NUMBER:
342700579
ADMINISTRATOR/
DIRECTOR:		MARIANNE R RICHARDSONFACILITY TYPE:
740
ADDRESS:641 FEATURE DRTELEPHONE:
(916) 921-1970
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 143TOTAL ENROLLED CHILDREN: 0CENSUS: 81DATE:
04/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Marianne RichardsonTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Chateau at River’s Edge RCFE on 4/3/25 at 9:00am to conduct a case management deficiencies inspection to address deficiencies observed in the process of conducting a complaint investigation regarding R1 (see confidential names list, LIC 811 dated 4/3/25).

In the course of the department’s investigation, the department identified the facility did not meet title 22 regulations for providing timely medical assistance for R1 as their bilateral injuries to both thighs were not in a state of healing and were in fact worsening. The facility documented concerns regarding R1’s wounds on 8/9/23. On 8/12/23 and 8/13/23, facility staff attempted to reach Home Health nurse responsible for wound care and on both dates there was no response from home health and no visits conducted to address worsening wounds. On 8/17/23 facility nurse notes identified wounds continuing to deteriorate. R1 was not transported to be evaluated at the hospital until 8/21/23 at the advice of R1’s physical therapist who observed a foul odor emanating from R1’s wounds.

Additionally, the home health and wound care order in place for R1 when they returned from skilled nursing on 7/24/23 was for a surgical wound on the hand/wrist. On 8/1/23 Home health was initiated, and no pressure injuries are noted. On 8/7/23 R1’s physical therapist observed two (2) “large wounds on buttocks” and R1 should have been re-evaluated for a change in condition. The facility did not have R1 re-evaluated. The department has also concluded the facility did not put in place any interventions to prevent worsening of wounds on R1’s thighs from prolonged sitting on the toilet seat such as a padded toilet seat or timed toileting to prevent R1 from prolonged sitting as well as sitting for extended periods of time in their wheelchair.

Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924
DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/03/2025
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The department has also concluded the facility not mot meet the requirements for basic services provided to R1. The department obtained evaluations and needs and services plans dated 7/22/23 that R1 requires “extensive” assistance for toileting. Multiple Home Health agency staff observed R1 on the toilet with no staff members present or aiding R1 who demonstrated sitting on the toilet for prolonged periods of time without intervention or assistance from staff members. Statements obtained from the administrator at the time of the incident described the resident as mostly independent. Per R1’s appraisal on 7/22/23 R1 was documented as needing standby assistance from staff members while toileting.

Per California code of regulations, Title 22, the following deficiencies are cited during today's inspection. Due the violation resulting in an injury to the resident, an immediate civil penalty is issued and the department will evaluate the deficiency for additional civil penalties.

Exit interview conducted and a copy of this report and appeal rights are left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2025 11:18 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CHATEAU AT RIVER'S EDGE, THE
FACILITY NUMBER: 342700579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2025
Section Cited
CCR
87405(a)(1)

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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by department review of facility records, home health care and
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Facility will provide a written plan of correction indicating the steps facility will take in regards to wound care and when to have the resident sent to the hospital for additional treatments interventions that may not have been successful in the assisted living environment.
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 physical therapy notes and hospital records that that facility did not seek timely medical attention for resident’s degenerating wounds on both legs as the facility continually reached out for wound care to make unscheduled visits to address wounds when staff members documented increased deterioration of resident’s wounds which posed an immediate health, safety and personal rights risk to resident in care.
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Type A
04/04/2025
Section Cited
CCR87463(f)

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Reappraisals: The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical
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Facility will conduct training for all caregivers on wound care and skin breakdown and the facility plan for communicating changes in conditions as it relates to wound care and skin issues that may occur in an assisted living environment. The training materials used in the training and written documentation of the communication plan to be provided to the department.
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professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record. This requirement was not met as evidenced by review of resident’s needs and services plan upon return from skilled nursing, staff interviews and documentation in resident’s file. Per the needs and services plan, R1 was identified as only needing a standby assistance for toileting. Statements and documentation obtained indicate that R1 would frequently sit on the toilet for extended periods of time and staff were not always present to ensure resident did not sit on the toilet for extended periods of time and as a result developed the injuries to both legs. Home health documented that R1 is a max 2 personal assist for toileting which was not documented or integrated into R1’s care plan which poses and immediate health, safety or personal rights risk to residents in care.
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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.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2025 11:18 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CHATEAU AT RIVER'S EDGE, THE
FACILITY NUMBER: 342700579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2025
Section Cited
CCR
87463(g)

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Reappraisals:
The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. This requirement was not met as evidenced by R1’s medical records, home health and physical therapy care notes and
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A written plan of correction indicating the specific timelines for reappraisals once it is documented/observed by facility staff that a resident has had a change in condition to wounds or skin breakdown.
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statements obtained by the department. the facility did not ensure corresponding changes to the care and supervision for R1 as R1 was not re-evaluated for changes in condition and no changes to R1’s care plan were made despite developing and worsening wounds on R1’s legs and no intervention in care and supervision were provided to the resident to prevent wounds from developing and worsening including but not limited to timed bathroom breaks and padded toilet seats. As a result, R1 incurred serious bodily injuries which poses an immediate health, safety and personal rights risk to resident in care.
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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.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025

LIC809 (FAS) - (06/04)
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