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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 09/24/2020
Date Signed: 09/25/2020 04:33:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
342700583
ADMINISTRATOR:TYLER BARNESFACILITY TYPE:
740
ADDRESS:2701 CAPITOL AVENUETELEPHONE:
(916) 447-4444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:81CENSUS: 50DATE:
09/24/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tyler Barnes, AdministratorTIME COMPLETED:
11:45 AM
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On 09/24/2020 at approximately 11:00AM Licensing Program Analyst (LPA) McCrory tele-visited the Chateau on Captiol Avenue Facility via FaceTime due to COVID-19 precautionary reasons. The tele-visit was conducted as an announced Case Management Health and Safety Check with Administrator (Admin) Tyler Barnes. This facility had prior COVID-19 Positive Cases, however is currently CLEAR of COVID-19.

Below is pertinent information regarding the visit:
  • Physical plant appears clean and free of debris.
  • Medical room on 4th floor -- door locked with locked cabinets inside of room for medicine storage.
  • MAR is electronic on laptop with log-in access only.
  • Thermostat temperature 70 Degrees Fahrenheit on 4th Floor.
  • Boxes of Personal Protective Equipment (PPE) stored in central location and include; gowns, masks, sanitizer wipes, gloves, shoe covers, goggles, and face shields.
  • A sign-in policy is enacted, routine symptom screening and hand washing station at one central entry point into facility.
  • Signage posted for Social Distancing, hand washing, cough etiquette, COVID-19 symptoms and reporting at entrance and throughout facility.
  • COVID-19 staff training with e-learning conducted online.
  • 80 hours of sick pay given to staff related to COVID-19.
  • Alternate staffing plan includes contract wtih RX Care, Ascent Care, and 123 Care.
  • Meals are staggered and reservations necessary for dining area.
  • Facility has a specific plan for managing residents with symptoms of acute respiratory illness.
  • Commonly touched surfaces are cleaned 3x a day or more (if used more frequently).
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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