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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 06/25/2021
Date Signed: 06/25/2021 11:55:09 AM

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:
06/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tyler Barnes TIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPAs ) Avelina Martinez conducted an unannounced case management visit on 06/25/2021 to deliverer a civil penalty associated with complaint 27-AS-20210311110614 . LPA Martinez identified herself and discussed the purpose of the case management visit with Tyler Barnes.

As a result of complaint 27-AS-20210311110614 findings, it was determined R1 sustained serious bodily injury. The facility was cited for the following deficiency: 87466 Observation of the resident on 06/03/2021. Moreover, the serious bodily injury warrants a civil penalty of $500.00. The civil penalty was assessed on today's date 06/25/2021 and can be found on the LIC421M.



Exit interview conducted. Appeal rights discussed and a copy given to the Administrator.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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