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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:36:11 AM


Document Has Been Signed on 04/29/2022 11:36 AM - It Cannot Be Edited

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: 29DATE:
04/29/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Raina SmithTIME COMPLETED:
12:00 PM
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On 4/29/2022 at 9:30 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a weekly health and safety check. LPA met with Director of Assisted Living, Raina Smith, and explained the purpose of the visit.

LPA toured and inspected the physical plant to ensure compliance with Title 22 regulations. There are currently 29 residents who reside at this facility.

LPA observed the facility is clean and in sanitary condition. LPA observed 2-day perishables and 7-day non-perishables food items. The hot water measured in rooms 511, 508, 408, 416, and 205 were within the required range of 105-120*F. The temperature inside measured at 76 degrees Fahrenheit which is within the required range of 68-85*F. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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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