342700583-1-26-2021-27-AS-KHOS-BXPQJZ-20210128111335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 01/26/2021
Date Signed: 01/26/2021 01:20:05 PM

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
08/13/2020 and conducted by Evaluator Jasmine McCrory

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200813122902

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: 46	DATE:	01/26/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Tyler Barnes, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal items.

INVESTIGATION FINDINGS:

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On 01/26/2021 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 allegation: Staff did not safeguard resident's personal items.

During the investigation, LPA interviewed staff, relevant parties, and reviewed documentation pertinent to the investigation of the allegation 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: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

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-20200813122902

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: 01/26/2021

NARRATIVE

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Licensing Program Analyst (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.

On 08/17/2020 LPA attempted to contact Reporting Party, LPA left a detailed voicemail. On 09/29/2020 at 4:15PM LPA attempted to contact R1 via cell phone. There was no answer and LPA left detailed a 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 09/29/2020 LPA reviewed Health and Services Evaluation Results for R1. Assessment took place on 12/17/2019 by facility Licensed Vocational Nurse (LVN) due to a change in condition. Documentation indicates R1 will have outbursts of anger, yelling, and will pull her own hair and bite her arms and fingers when very frustrated. R1 has current or history of occasional disruptive, aggressive, or socially inappropriate behavior.

On 10/06/2020 LPA interviewed a staff identified as S1 who stated the following: R1 needs a higher level of care and has memory issues. S1 states she saw pill bottles, papers, boxes in R1's Room and R1 needs help unpacking and storing.

On 01/21/2021 11:25 AM LPA contacted Power of Attorney (POA) who states R1 is okay and moved from Chateau on Capitol. POA states R1 had an overflow of boxes in an additional room. POA states R1 spends tons of money and that R1 keeps buying things like designer clothes. POA states R1 has meltdowns where she yells and screams and throws things. POA states R1 broke her cell phone by throwing it and now the screen is completely black.

Based on interviews, documentation review, observations and the inability to obtain evidence from R1, the LPA finds these allegations to be (U) UNSUBSTANTIATED. This agency has investigated the above listed allegation. 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: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

LIC9099 (FAS) - (06/04)

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