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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005689
Report Date: 07/26/2023
Date Signed: 07/26/2023 01:03:00 PM


Document Has Been Signed on 07/26/2023 01:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CHATEAU ROYALE CAREFACILITY NUMBER:
347005689
ADMINISTRATOR:PAMINTUAN, JOHN PAULFACILITY TYPE:
740
ADDRESS:2745 CALIFORNIA AVETELEPHONE:
(916) 365-7994
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:John Paul PamintuanTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required 1-year inspection. LPA met with Caregiver, Cadine Jackson, and explained the purpose of the visit. Caregiver then contacted Administrator, John Paul Pamintuan, who arrived shortly to the facility.

The facility has (6) residents, (1) on hospice services, facility is licensed for (6) with hospice waiver of (2).

LPA and Administrator toured the interior and exterior of the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (6) resident bedrooms, (1) common bathroom, kitchen, laundry room and staff room. In the areas toured no immediate health, safety, or personal rights violations were observed.

During today's inspection, LPA observed a sharps, medication and toxins to be locked and secured. LPA observed facility temperature to be 71*. LPA observed fire extinguisher to last be serviced on 01/09/2023.

LPA obtained a copy of Administrator Certificate and liability insurance. LPA requested: LIC 500 and client roster. Documents to be submitted to LPA via email by due date on Friday August 4, 2023.

LPA conducted a file review of (2) staff and (2) resident records. LPA and Administrator completed the full CARE tool together and found facility to be in compliance.

Exit interview conducted and copy of report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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