342700583-1-25-2021-27-AS-KHOS-BXMS92-20210126124001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 01/25/2021
Date Signed: 01/25/2021 11:19:10 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
09/15/2020 and conducted by Evaluator Jasmine McCrory

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200915164759

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: 44	DATE:	01/25/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Tyler Barnes, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident(s) room is dirty.
Resident(s) toileting needs are not being met.
Resident(s) bathing needs are not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) McCrory contacted Facility Administrator (Admin) Tyler Barnes to deliver complaint findings over the phone due to COVID-19 and precautionary measures. LPA informed Admin of the purpose of the call. Community Care Licensing (CCL) received the following complaint allegations: Resident(s) room is dirty; Resident(s) toileting needs are not being met; Resident(s) bathing needs are not being met.

During the investigation, LPA interviewed staff, relevant parties, and reviewed documentation pertinent to the investigation of the allegations above.

On 09/24/2020 at 11:45AM -- after conducting Case Management: COVID-19 Facility Assessment -- Licensing Program Analyst (LPA) McCrory viewed two resident rooms via FaceTime on Administrator (Admin) Tyler Barnes' phone. (CONT.)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

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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Control Number 27-AS-20200915164759

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/25/2021

NARRATIVE

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LPA McCrory viewed the first room which was occupied by Resident identified as R1. R1 allowed Admin to enter without objection. During the video chat LPA viewed medication bottles on the counter, boxes stacked in the room, and overall clutter. After leaving the room Admin stated that R1 has reoccurring orders from the Home Shopping Network (HSN) and the overflow of boxes are taking over a vacant extra room. Admin states Power of Attorney (POA) is noticing some of the behaviors.

Admin went to the second room where Residents identified as R2 and R3 reside. LPA witnessed the room was cluttered. There was not a substantial amount of space for Admin to enter. R3 stated the son was coming up to tighten up the room. However, LPA is aware that there is a limit on visitations due to COVID-19 Precautionary reasons.

On 09/29/2020 Licensing Program Analyst (LPA) McCrory reviewed physician’s report for R1 which indicated R1 is not able to bathe self. At approximately 4:15PM LPA attempted to contact R1 via cell phone. There was no answer and LPA left detailed voicemail message. On 01/21/2021 at 11:20 AM LPA again attempted to contact R1 however, the call went straight to voicemail and the voicemail box was full.

On 01/21/2021 11:25 AM LPA contacted POA of R1 via phone. POA states R1 was not showering, only taking sponge baths and that was due to R1's refusal of facility services. POA states staff would constantly come and clean R1 for toileting accidents. POA states R1 has an overflow of boxes in an additional room.

On 01/21/2021 at 10:45AM Licensing Program Analyst (LPA) McCrory contacted R3 via phone. The following pertinent information was obtained during the call: R3 states she is doing okay. R3 states she has hired an independent provider for bed baths that comes in multiple times a week. R3 states that the independent provider stays over (assigned time) to do housekeeping. R3 sates her son has not been able to come to do any cleaning because this place (the facility) is on lockdown (limited visiting due to COVID-19 precautions). R3 states most of the time she is able to get changed pretty well.

Based on interviews and observations, the LPA finds these allegations to be (U) UNSUBSTANTIATED. This agency has investigated the above listed allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred therefore, we have found the allegations to be UNSUBSTANTIATED.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

LIC9099 (FAS) - (06/04)

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