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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700583
Report Date: 05/09/2022
Date Signed: 05/09/2022 04:59:29 PM

Unsubstantiated


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
05/04/2022 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20220504094355
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):
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No activities at the facility.
Meals being served does not meet resident dietary needs.
Facility does not arrange transportation to medical appointments.
INVESTIGATION FINDINGS:
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On 05/09/2022 at 9:00 am, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA met with Tyler Barnes and explained the purpose of today's visit.

Throughout the course of the investigation, LPA conducted interviews and toured the facility. LPA Martinez requested facility activities calendar, which was provided by facility staff. The facility has an Activities Director, and LPA Martinez observed activities on 05/09/2022. LPA Martinez attended the 10:15 am activity, and no residents attended. LPA Martinez attended the 11:15 Bingo activity on 05/09/2022, and 2 resident attended. LPA Martinez was informed by the Activities Director that 2 residents attended the 2:30 PM scheduled activity. LPA attended the 4 PM activity, and no residents attended. Moreover, 5 out of 5 resident reported activities are still being provided by the facility.

Continued...
Unsubstantiated
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-20220504094355
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
VISIT DATE: 05/09/2022
NARRATIVE
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4 out 5 residents reported the food being served is nutritious. However, the facility was cited on 05/09/2022 under complaint: 27-AS-20220218100311 in regards to food supply. LPA Martinez observed a limited supply of fruits, vegetables, meats, milk, and canned foods. The facility was cited and citations can be found on 05/09/2022 9099 report, and a plan of correction has been implemented. Moreover, 5 out 5 residents reported not having issues with transportation. Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2