342700579-4-3-2025-27-AS-CACL-DFJSAU-20250408134256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700579
Report Date: 04/03/2025
Date Signed: 04/03/2025 11:15:33 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
08/22/2023 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20230822112418

FACILITY NAME:	CHATEAU AT RIVER'S EDGE, THE		FACILITY NUMBER:	342700579
ADMINISTRATOR:	MICHAEL TALANI		FACILITY TYPE:	740
ADDRESS:	641 FEATURE DR		TELEPHONE:	(916) 921-1970
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	143	CENSUS: 81	DATE:	04/03/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marianne Richardson		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent resident from developing multiple pressure injuries

INVESTIGATION FINDINGS:

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

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 conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator, Marianne Richardson and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the department was unable to corroborate the allegations. The department conducted interviews with four (4) facility staff members and four (4) residents. Department also conducted interview with home health personnel HH1 and HH2 (see confidential names list, LIC 811) The department also obtained records for alleged victim, (R1) including physician’s report for R1, R1’s needs and services plan and documented care notes from facility staff and home health personnel.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (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

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 27-AS-20230822112418

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: 04/03/2025

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

Facility staff interviews demonstrated staff were aware of resident’s wounds on thighs and had communicated with home health agency on 8/4/23 that was already providing wound care for R1 for preexisting wounds. As all community care licensed facilities are non-medical, facility staff were not trained to provide wound care and provided documented outreach to home health agencies responsible for wound care. Home health did not diagnose the injuries to R1’s thighs as pressure injuries but as “trauma skin injury”. Facility and home health records indicate Home health visits for wound care occurred on 8/7/23, 8/9/23, 8/14/23, 8/15/23 and 8/18/23. Prior to R1 being sent to the hospital for treatment on 8/21/23 the facility provided multiple attempts at reaching R1’s home health agency for wound care as documentation in facility records indicate the staff members did not believe the wounds observed were healing and were deteriorating per facility notes for R1.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 2