<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440541
Report Date: 11/01/2024
Date Signed: 11/01/2024 07:16:42 PM

Document Has Been Signed on 11/01/2024 07:16 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CHATEAU PLEASANT HILLFACILITY NUMBER:
071440541
ADMINISTRATOR/
DIRECTOR:		JOHN MCCRAWFACILITY TYPE:
740
ADDRESS:2726-2770 PLEASANT HILL RD.TELEPHONE:
(925) 935-1660
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 165CENSUS: 149DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Ruth Hernandez-Saleh Resident LiaisonTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/01/2024 at 02:00 PM, Licensing Program Analysts (LPAs) D. Doidge and L. Alexander arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Ruth Hernandez-Saleh Resident Liaison at 02:10PM. Administrator Jon McCraw certification 6042869740 expires on 12/04/2024, joined later.

LPAs toured the facility with including but not limited to 6 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76 degrees F. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ bathrooms were measured at 110, 107.9, 108.4, 106, and 105 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 are locked and inaccessible to residents in care. Fire Extinguisher dated 07/24/2024.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/08/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
Liability Insurance

Reviewed:
LIC 610E Emergency Disaster Plan

Exit interview conducted and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: David Doidge
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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
Document Has Been Signed on 11/01/2024 07:16 PM - It Cannot Be Edited


Created By: David Doidge On 11/01/2024 at 06:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CHATEAU PLEASANT HILL
FACILITY NUMBER: 071440541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as Comet cleaner was found unlocked in kitchen were food was being prepared, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2024
Plan of Correction
1
2
3
4
LPAs observed kitcehn staff removed cleaner and stored in locked pantry. Defeciency cleared during visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Bennett Fong
LICENSING EVALUATOR NAME:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2