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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 03/04/2022
Date Signed: 03/04/2022 08:46:10 AM


Document Has Been Signed on 03/04/2022 08:46 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CHATEAU ON CAPITOL AVENUE, THEFACILITY NUMBER:
342700583
ADMINISTRATOR:TYLER BARNESFACILITY TYPE:
740
ADDRESS:2701 CAPITOL AVENUETELEPHONE:
(916) 447-4444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:81CENSUS: 38DATE:
03/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Raina Smith.TIME COMPLETED:
09:12 AM
NARRATIVE
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Licensing Program Analysts (LPA ) Avelina Martinez conducted an unannounced case management visit. LPA Martinez identified herself and discussed the purpose of the case management with Raina Smith.

The purpose of the case management visit is to follow up on deficiency found during 27-AS-20211011085307 complaint investigation. LPA Martinez request a LIC 621 Client/Resident Personal Property and valuables form, and LPA Martinez was informed by the Administrator that resident 1 (R1) did not have one in her file. The facility did not adhere to Personal Property and Valuables 1569.153 Health and Safety Code regulation which states, "(d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly."

LPA Martinez reviewed R1's 02/16/2021 Chateau on Capitol Avenue Service Plan and R1's May 17, 2021 Physician Report (LIC 602). LPA Martinez observed the following inconstancies: R1's 02/16/2021 Chateau on Capitol Avenue Service Plan states, "Mobility/Ambulation Enabling Devices and Methods: Non-Ambulatory, Extensive: requires 1 person total assist or wheelchair assist... transferring extensive requires 1 total assistance. R1's May 17, 2021 Physician Report (LIC 602) document reports R1 is not able to transfer independently. In addition the LIC 602 reported R1 as being bedridden.

Moreover, R1's 02/16/2021 Chateau on Capitol Avenue Service Plan states," meal consumption...cutting up of food, opening cartons/packages; may need encouragement to select menu items." R1's 05/17/2022 LIC 602 reported no special diet. Hospice documentation does not state a special diet is required. As a result, the facility did not notate significant physical and medical changes on reappraisals, and R1's health certification form LIC 602 did not reflect accurate information. Therefore the facility will be cited. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code and can be found on the 809-D page. An Exit interview was conducted and appeal rights printed and given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/04/2022 08:46 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: CHATEAU ON CAPITOL AVENUE, THE
FACILITY NUMBER: 342700583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/02/2022
Section Cited

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ยง1569.153(d) Theft and loss program; standards, property inventories and surrender of personal effects; secured areas. A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly.
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This requirement is not met as evidenced by:
Based on interviews and records review, the licensee did not ensure personal property and valuables inventory list was completed for R1. This posed a potential health and safety risk to R1.
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Type B
03/02/2022
Section Cited

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Reappraisals 87463(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition...
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This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure R1' health changes were documented on the health and service evaluation results reappraisals. This posed an immediate health and safety risk to R1.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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