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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440541
Report Date: 10/27/2023
Date Signed: 10/27/2023 06:37:47 PM


Document Has Been Signed on 10/27/2023 06:37 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CHATEAU PLEASANT HILLFACILITY NUMBER:
071440541
ADMINISTRATOR:JOHN MCCRAWFACILITY TYPE:
740
ADDRESS:2726-2770 PLEASANT HILL RD.TELEPHONE:
(925) 935-1660
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:165CENSUS: DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Jon McCraw, Executive DirectorTIME COMPLETED:
06:50 PM
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On 10/27/2023 at 12:20 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Jon McCraw and explained the purpose of the visit. The facility’s fire clearance was approved for 2770 Pleasant Hill Rd. 50 Clients May Be All Non-Ambulatory First Floor Only. 2726 Pleasant Hill Rd, 76 Clients May Be All Non-Ambulatory First and Second Floor. Hospice Waiver for Six (6) Residents.

LPA toured the facility with Jon including but not limited to 4 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 105, 106, 108 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

At 2:50 PM, LPA reviewed 7 residents records. At 4:30 PM, LPA reviewed 10 staff records and 10 of 10 have current first aid training and associated to the facility.

LIC 809C...Continued
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CHATEAU PLEASANT HILL
FACILITY NUMBER: 071440541
VISIT DATE: 10/27/2023
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LIC809 Continued....

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/03/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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