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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 05/09/2022
Date Signed: 05/09/2022 05:02:06 PM

Substantiated


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
02/18/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220218100311
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: 20DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tyler BarnesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not providing adequate food service to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 05/09/2022 at 9:00 am to deliver complaint findings, LPA met with Administrator, Tyler Barnes, and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and tours of the facility kitchen. During the facility kitchen tour, LPA observed 2 half filled gallons of milk. LPA was informed that the facility did not have additional milk. Additionally, food in the freezer was not sealed and/or covered to be protected against contamination. Furthermore, there were no expiration dates on of some of the food. LPA Martinez also observed a limited supply of food, such as, snacks, fruits, meats, vegetables and coffee.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations
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: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
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 2
Control Number 27-AS-20220218100311
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: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2022
Section Cited
CCR
87555(28)
1
2
3
4
5
6
7
87555(a)General Food Service Requirements: The total daily diet shall be of the quality and in the quantity...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to: Conduct a food service training by 5/23/2022. Email LPA training document by POC date 5/23/22.
8
9
10
11
12
13
14
Based on observation, prepared chicken and salad was left uncovered in the freezer. There were no expiration dates on the chicken or salad. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
05/23/2022
Section Cited
CCR
87555(26)
1
2
3
4
5
6
7
87555 (26) General Food Service Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based on observation
1
2
3
4
5
6
7
Administrator agreed to: Conduct a food service training by 5/23/2022. Email LPA training document by POC date 5/23/22.
8
9
10
11
12
13
14
LPA Martinez observed a limited food supply. Limited snacks, coffee, snacks, fruits and milk. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2