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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 06/03/2021
Date Signed: 06/04/2021 08:36:55 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, THEFACILITY NUMBER:
342700583
ADMINISTRATOR:TYLER BARNESFACILITY TYPE:
740
ADDRESS:2701 CAPITOL AVENUETELEPHONE:
(916) 447-4444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:81CENSUS: 41DATE:
06/03/2021
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Tyler BarnesTIME COMPLETED:
05:09 PM
ALLEGATION(S):
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Facility did not provide resident with prescribed oxygen.
Facility staff did not observe change in resident's health condition.
Facility staff did not obtain timely medical care for resident
INVESTIGATION FINDINGS:
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On 06/03/2021 at 3:55 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Tung Truong 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, reviewed facility records, and toured the facility. Resident 1’s (R1) temperature ranged from 97 degrees and 97.6 degrees between 03/01/2021 and 03/05/2021. Additionally, R1's temperature was 90 degrees on 03/07/2021 and 95.5 degrees on 03/08/2021. Furthermore, R1 refused medication on 03/07/2021, and R1’s primary care physician was informed. It was also noted on 03/07/2021 that R1 did not eat breakfast, lunch, and dinner. It was also reported R1 had low blood pressure. Moreover, the Director of Assisted Living reported R1 had a significant change beginning on 03/08/2021. On 03/08/2021, staff 1 (S1) reported R1's health condition change to R1’s responsible party, However, S1 reported R1’s health conditioned change did not warrant a 9-1-1 call. Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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)
Page: 1 of 6
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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On 03/08/2021, R1 was taken to a medical appointment by her responsible party. Based on the 03/08/2021 physician’s assessment, R1 should have been taken to the emergency room earlier on 03/08/2021. The physician’s assessment indicated R1 was having tremors, appeared to be severely dehydrated, and had low blood pressure. It was also noted there were concerns that the facility did not report R1's low blood pressure to her primary care physician.

Furthermore, R1 was taken to the emergency room during the 03/08/2021 doctor’s appointment. R1 was placed on a central line due to persistent shock. The persistent shock was secondary to sepsis and hypothermia. R1’s temperature was 91.5 degrees at the emergency department. R1 was also diagnosed with a urinary tract infection, which was secondary to E.coli. It was noted R1 had an overall poor health status, which included a do not resuscitate directive. R1 passed away on 03/10/2021. As a result, the facility staff did not seek timely medical care for R1, and the facility staff did not address R1's change in condition.

It was also reported R1 was prescribed oxygen, and if R1 did not use oxygen when needed she would experience shortness of breath. However, based on documentation submitted during the investigation, R1's oxygen machine was not hooked up properly, and oxygen tubes had mildew. Furthermore, it was learned some facility staff were not aware R1 required oxygen. Moreover, the facility did not have a copy of R1's oxygen order and did not reach out to R1's primary care physician for an order. During interviews it was also reported if a resident is on oxygen and does not have an order in their file, staff should reach out to the resident's primary care physician. The facility staff did not ensure oxygen was being used in accordance to R1's physician's orders.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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)
Page: 4 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/04/2021
Section Cited
CCR
87466
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87466 Observation of the resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental... and that appropriate assistance is provided when such observation reveals un-met needs...This requirement is not met as evidenced by:
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Facility administrator agrees to the following: implement 2 hour check on residents returning from hospital. Complete a in-service on observation of residents by POC date 06/11/2021. Facility administrator will email LPA an agenda and training materials by POC date 06/04/2021.
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Based on record review and interviews the licensee did not address body temperature changes, refusing to eat changes in memory . This posed an immediate health and safety risk to R1.
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Request Denied
Type A
05/28/2021
Section Cited
CCR
87465(a)(g)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis ...
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Facility administrator agrees to Complete a in-service on incidental medical and dental care by POC date 06/11/2021. Facility administrator will email LPA an agenda and training materials by POC 06/04/2021.
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure R1 received timely medical care on 03/08/2021 for blood pressure, body temperature, dehydration symptoms, which 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: 06/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/28/2021
Section Cited
CCR
87618(a)(1)
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87618 Oxygen Administration - Gas and Liquid (a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances:(1) If the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and
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The administrator conducted reappraisals for all resident on oxygen. On 05/20/2021 Director of Assisted Living conducted an audit on all residents on oxygen and updated files. POC cleared at time of visit
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 is able to administer it him/herself. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure R1 was mentally and physically capable of operating the her oxygen. This posed an immediate health and safety risk to R1.
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Request Denied
Type B
05/28/2021
Section Cited
CCR
87463(a)
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87463 Reappraisals (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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The administrator agrees to complete resident reappraisals every 30 days or earlier if there is a change of condition. Administrator will email LPA a list of residents reappraisals list for June and July 2021
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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: 06/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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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Moreover, R1's 02/18/2021 health and service evaluation report indicated R1 had no neurocognitive impairments, such as, orientation: person, place, time, and situation. It was also reported R1 was independent with all aspects of oxygen utilization. However, R1's doctor's notes indicated R1 was having advanced memory problems. In addition, staff indicated they thought R1 had dementia. Staff reported R1 sometimes talked about her deceased husband as if he were still alive. The facility did not ensure R1 was mentally capable of operating the oxygen equipment and was able to determine her need for oxygen and was able to administer the oxygen independently.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

As a result of this incident, R1 sustained serious bodily injuries, the violation warrants a civil penalty assessment. At this time, the civil penalty assessment is under review, and a civil penalty determination is pending by the Department. Once the civil penalty assessment has been determined, an LPA will return at a future date to assess the civil penalty.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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)
Page: 6 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/02/2021
Section Cited
CCR
87611(e)
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87611 General Requirements for Allowable Health Conditions:(e)In addition to Sections 87465(a) and 87464(d) the licensee shall ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met.
This requirement is not met as evidenced by:
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Facility administrator agrees to complete a in-service on general requirements for allowable health conditions by POC date 06/11/2021. Facility administrator will email LPA an agenda and training materials by 06/04/2021.
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Based on record review and interviews the licensee did not ensure to maintain a physician's order for the oxygen and follow the physician's orders. 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: 06/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6