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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 06/03/2022
Date Signed: 06/03/2022 09:21:00 AM


Document Has Been Signed on 06/03/2022 09:21 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: 0DATE:
06/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Raina Smith and Dan WilliamsTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility announced on 06/03/2022 at 8:55 AM to conduct a facility closure visit. LPA met with Raina Smith and Dan Williams and explained the purpose of the visit.

The purpose of the visit today, is in response to the facility closing. As of today, all residents belongings will be removed from the facility. During today's visit, the last two residents' belongings were being removed from the facility, and residents are leaving the facility today. Moreover LPA Martinez toured the facility with Raina Smith.

Effective today June 3, 2002, the facility is closed. LPA Martinez received the original License. Furthermore, please complete the following closure survey. Link to survey for Facility Closure provided to the facility.www.surveymonkey.com/r/facilityclosure

An exit interview was conducted and a copy of this report was given 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: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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