<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:34:20 AM


Document Has Been Signed on 04/29/2022 11:34 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:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Raina SmithTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/29/2022 at 9:30 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a proof of correction (POC) visit in regard to deficiencies cited on 4/22/2022. LPA met with Director of Assisted Living, Raina Smith, and explained the purpose of the visit.

LPA measured the water temperature in the following units:
511 @ 119.5 degrees Fahrenheit
508 @119.8 degrees Fahrenheit
408 @ 119.1 degrees Fahrenheit
416 @ 119.3 degrees Fahrenheit
205 @ 119.5 degrees Fahrenheit

*Deficiency cited under Title 22 Regulation 87303(e)(2) – Cleared. Proof of correction was submitted on 4/22/2022. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter. LPA advised Raina to lower the water temperature to roughly 113.0 degrees Fahrenheit

Exit interview conducted and a copy of this report provided.
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)
Page: 1 of 1