342700583-9-1-2021-27-AS-KHOS-C6NJWS-20210908072513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 09/01/2021
Date Signed: 09/01/2021 10:49:14 AM

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
06/24/2021 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210624134437

FACILITY NAME:	CHATEAU ON CAPITOL AVENUE, THE		FACILITY NUMBER:	342700583
ADMINISTRATOR:	TYLER BARNES		FACILITY TYPE:	740
ADDRESS:	2701 CAPITOL AVENUE		TELEPHONE:	(916) 447-4444
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95816
CAPACITY:	81	CENSUS: 38	DATE:	09/01/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Tyler Barnes.		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable death.
Staff did not seek resident medical attention.

INVESTIGATION FINDINGS:

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

On 09/01/2021 at 10:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Avelina Martinez met with Tyler Barnes and explained the purpose of today's visit.

Throughout the course of this investigation, the Department conducted interviews and reviewed facility records. It was learned resident 1 (R1) had not passed away. R1 relocated to a different assisted living facility. In addition, R1 reported no concerns with the care services being provided at this facility. R1 reported being independent with all activities of daily living. R1 reported the only service being provided while residing at this facility was medication administration. Furthermore, R1 was not receiving incontinent care at this facility.
This agency has investigated the complaint alleging questionable death and staff did not seek resident medical attention in a timely manner. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Tyler Barnes, and a copy of this report was given to the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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