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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 06/01/2022
Date Signed: 06/01/2022 03:16:48 PM


Document Has Been Signed on 06/01/2022 03:16 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: 2DATE:
06/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Dan Williams and Raina SmithTIME COMPLETED:
03:30 PM
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On 06/01/22 at 3:10 pm, Licensing Program Analysts (LPAs) Avelina Martinez and Arrielle Pascula arrived at this facility unannounced to conduct a health and safety check. LPAs met with Dan Williams and Raina Smith and explained the purpose of the visit.

LPAs toured and inspected the physical plant inside to ensure compliance with Title 22 regulations. There are currently 2 residents who reside at this facility. There are three caregivers, two maintenance staff, one receptionist, one kitchen staff working during the PM shift. Additionally, Align management staff is present in the facility, and will remain until the facility is closed.

LPA observed the facility to be clean and sanitary. LPA observed an adequate supply of food for 2 residents. The temperature inside was set to 76 degrees Fahrenheit, which is within the required range of 68-85*F.

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

Exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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