342700583-6-4-2021-27-AS-KHOS-C4NLNJ-20210706085421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 06/03/2021
Date Signed: 06/04/2021 08:37:48 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
03/11/2021 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210311110614

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: 41	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Tyler Barnes		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's property.
Facility staff were not keeping residents rooms clean.
Facility staff did not meet resident's hygiene needs.
Questionable death

INVESTIGATION FINDINGS:

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On 06/03/20221 at 3:55 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Tung Troung 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 and reviewed facility records. A 02/22/2021 facility communication note to R1's primary care phyiscian stated R1 was having frequent loose stool and not calling for help. Moreover, 3 out of 3 facility staff stated resident 1 (R1) refused to wear breifs. During interviews, it was also reported R1 was refusing to change out of dirty clothing and cleaning body. As a result, it was determined there was not a preponderance of evidence to substantiate facility staff did not meet resident's hygiene needs.

Continued...

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: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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-20210311110614

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: 06/03/2021

NARRATIVE

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3 out 3 facility staff reported R1's carpet and flooring needed to be deep cleaned regularly due to R1 refusing to wear briefs and having multiple bowel movements. It was also noted R1 refused cleaning near her bed and television. As a result, it was determined there was not a preponderance of evidence to substantiate that facility staff were not keeping R1's room cleaned. Moreover R1's admission agreement did included a personal property list. Furthermore, an LIC 621 property list was not completed. Based on a file review, it was determined there was not a preponderance of evidence to substantiate that facility staff did not safeguard R1's hearing aids.

On 03/08/2021, R1 was admitted to the hospital and passed away on 03/10/2021. R1's death certificate stated the cause of death was septic shock, acute renal failure, and e-coli urinary track infection. Furthermore, it was noted that the progression of R1's health condition, resulted in her death.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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