342700583-2-11-2021-27-AS-KHOS-BYALTT-20210216080253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 02/11/2021
Date Signed: 02/11/2021 01:48:50 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
06/04/2020 and conducted by Evaluator Jasmine McCrory

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200604083557

FACILITY NAME:	CHATEAU ON CAPITOL AVENUE, THE		FACILITY NUMBER:	342700583
ADMINISTRATOR:	MAURER, JENNIFER		FACILITY TYPE:	740
ADDRESS:	2701 CAPITOL AVENUE		TELEPHONE:	(916) 447-4444
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95816
CAPACITY:	81	CENSUS: 43	DATE:	02/11/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Tyler Barnes, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Uncleared adult
Uncleared adult handles the resident in a rough manner
Staff is mismanaging residents' medications
Financial abuse

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: Uncleared adult; Uncleared adult handles the resident in a rough manner; Staff is mismanaging resident’s medication; financial abuse

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

Regarding the allegation of: uncleared adult
The Reporting Party (RP) alleges that third hand information received indicates the facility staff are not cleared to work in the facility. On 02/03/2021 LPA viewed a facility staff roster and compared the names to the LIS system database. (CONTINUED)

Unfounded

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: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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-20200604083557

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: 02/11/2021

NARRATIVE

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During the review the names on the staff roster compared to LIS system, reflected staff have the required criminal record background clearance.

Regarding the allegation of: uncleared adult handles the resident in a rough manner
The RP alleges that third hand information received indicates the facility staff providing care for Resident (R1) do not have clearance and handle R1 in a rough manner. During the investigation, LPA interviewed Administrator, Hospice Staff, relevant parties, and reviewed documentation pertinent to the investigation of the allegations above. On 01/26/2021 LPA interviewed facility Administrator who indicated Hospice provided showers for R1 while in care. The Hospice Certification and Plan of Care for R1 dated 04/27/2020 indicated Aides (Home Health Aides) assist with bathing and use Shower Chair Mondays, Wednesdays, and Fridays. Aides assist patient with dressing every visit. On 02/03/2021 LPA reviewed additional documents provided by Hospice and there was no indication of skin tears. On 01/26/2021 LPA interviewed Hospice Staff who indicated R1 was happy and facility Licensed Vocational Nurse (LVN) took very good care of R1.

Regarding the allegation of: staff is mismanaging resident’s medication
The RP alleges that third hand information received indicates facility staff are stealing R1’s medication. On 02/03/2021 LPA reviewed Medication Administration Record (MAR) for R1 which covered the months of May and June 2020. This records review indicates either; medication was not administered due to patient refusal and hospice was then notified; or medication was given to family to give to R1 after refusal. On 01/26/2021 LPA interviewed Hospice Staff who indicated there was never any medication issues. On 01/26/2021 LPA interviewed facility Administrator who indicated there were no complaints related to medication administration or missed medication regarding R1.

Regarding the allegation of: financial abuse
The RP alleges that third hand information received indicates facility staff financially abused R1. On 01/26/2021 LPA interviewed Hospice staff who indicated the Power of Attorney (POA) oversees the finances of R1. There is no indication or reports of financial abuse as it relates to the facility staff. On 01/26/2021 LPA interviewed Admin who states there were no complaints related to financial abuse.

Based on interviews, documentation review, and observations, the LPA finds this allegation to be (U) UNFOUNDED. This agency has investigated the complaint alleging: Uncleared adult; Uncleared adult handles the resident in a rough manner; Staff is mismanaging resident’s medication; and financial abuse. We have found the complaint was UNFOUNDED, meaning that the allegations are false, could not have happened, and/or is without a reasonable basis.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCrory	TELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC9099 (FAS) - (06/04)

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