342700583-9-1-2021-27-AS-KHOS-C6NJWT-20210908072514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 09/01/2021
Date Signed: 09/01/2021 10:48:18 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

Resident was left in urine soaked clothing for an extended period of time.

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 Martinez met with Tyler Barnes and explained the purpose of today's visit.
Throughout the course of this investigation, the Department conducted interviews, reviewed facility records, and toured the facility. LPA Martinez interviewed resident 2 (R2). Resident 2 was not able to provide detailed information in regards to the care being provided by facility caregivers. Moreover, resident 3 (R3) reported caregivers are doing well and are providing care. Resident 4 (R4) reported having no issues or concerns with the care being provided by caregivers. Resident 5 (R5) reported being independent with incontinent care and is satisfied with the care being provided by the caregivers.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of the report was provided to Tyler Barnes.

Unsubstantiated

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)

Page: 1 of 1