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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 06/03/2021
Date Signed: 06/24/2021 04:21:10 PM

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: 41DATE:
06/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Tyler Barnes TIME COMPLETED:
05:00 PM
NARRATIVE
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An unannounced case management visit was conducted by Licensing Program Analysts (LPAs) Avelina Martinez and Tung Truong on 06/03/2021 at 3:55 PM. LPA met with the facility administrator and explained the purpose of the visit.

The purpose of the case management visit is to follow up on a learned deficiency during a complaint investigation 27-AS-20210311110614. The following deficiency was discovered:


The facility file did not contain a personal property and valuables inventory list. The facility did not adhere to Personal Property and Valuables 1569.153 Health and Safety Code regulation which states, "(d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly."

As a result the following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Deficiency cited on the 809 D page.

Exit interview was conducted and appeal rights and 809 report was printed and 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: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2021
Section Cited

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ยง1569.153Theft and loss program; standards, property inventories and surrender of personal effects; secured areas. (d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly.
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This requirement is not met as evidenced by:
Based on interviews and records review, the licensee did not ensure personal property and valuables inventory list was completed for R1. This posed a potential health and safety risk to R1.
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POC cleared at time of visit.

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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: 06/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2021
LIC809 (FAS) - (06/04)
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