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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 04/22/2022
Date Signed: 04/22/2022 12:30:01 PM


Document Has Been Signed on 04/22/2022 12:30 PM - 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: 32DATE:
04/22/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tyler Barnes, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 4/22/2022 at 11:00 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a health and safety check. LPA met with Administrator Tyler Barnes and explained the purpose of the visit.

LPA toured and inspected the physical plant inside and outside to ensure compliance with Title 22 regulations. There are currently 32 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 room 511, 508, and 411 were 126.5 degrees Fahrenheit which are not within the required range of 105-120*F. The temperature inside observed at 78 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.

LPA discussed with Administrator Tyler Barnes to provide Licensing a copy of the 60-day notice that the facility will provide to the residents.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview conducted, a copy of this report, 809-D and appeal rights given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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Document Has Been Signed on 04/22/2022 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2022
Section Cited

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Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows... Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidence by:
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Based on observation, the licensee did not ensure that water temperature are maintained between 105-120 degrees Fahrenheit. Water temperature measured in room 511, 508, and 411 were at 126.5 degrees Fahrenheit. This poses an immediate health and safety risk to residents in care.
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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: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
LIC809 (FAS) - (06/04)
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