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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 08/23/2021
Date Signed: 08/23/2021 05:00:56 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: 37DATE:
08/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tyler Barns TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPA ) Avelina Martinez conducted an unannounced case management visit on 08/23/2021. LPA Martinez identified herself and discussed the purpose of the case management with Tyler Barns.

The purpose of the case management visit is to follow up on deficiency found during a complaint investigation visit on 08/23/2021. During today's visit, LPA reviewed facility documents and conducted interviews. LPA Martinez reviewed weekly menus for week 08/16/2021-08/22/2021 and week 08/23/2021-08/29/2021. It was learned on 08/22/2021, the facility had insufficient staff to prepare the scheduled meal reported on the weekly menu. Due to insufficient staff, the facility ordered dinner from Round Table Pizza and Old Spaghetti Factory.

Additionally, during today's visit (08/23/2021), there was insufficient kitchen staff. As a result, the scheduled dinner meal was not prepped or prepared. As a result, frozen food trays from Costco were purchased and served for dinner. The licensee did not ensure the facility had sufficient food service staff to prepare meals, and did not ensure food service staff schedules met the needs of the residents.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.


Exit interview conducted and appeal rights printed.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2021
Section Cited

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87555 (18) General Food Service Requirements:(18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.
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 This requirement was not met as evidence by: based on record review and interviews the licensee did not ensure the facility had sufficient food service staff to prepare meals . This posed an immediate health and safety risk to residents in care.
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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: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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