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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440541
Report Date: 02/11/2025
Date Signed: 02/11/2025 02:39:26 PM

Document Has Been Signed on 02/11/2025 02:39 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/
DIRECTOR:		JOHN MCCRAWFACILITY TYPE:
740
ADDRESS:2726-2770 PLEASANT HILL RD.TELEPHONE:
(925) 935-1660
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 165TOTAL ENROLLED CHILDREN: 0CENSUS: 143DATE:
02/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jon McCraw, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 02/11/2025 at 2:00 PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Executive Director, Jon McCraw, and explained the purpose of visit.

While LPA L. Alexander was conducting a complaint investigation(15-AS-20250205123313) on 02/11/2025. During record review LPA observed that facility did not notify Community Care Licensing Division (CCLD) of Resident's (R1) hospitalization. LPA interviewed Staff (S1) and S1 stated that S2 completed an incident report but did not have the receipt of date and time incident report was faxed to CCLD. LPA obtained a copy of an Incident Report that was generated by S2.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
Bennett FongTELEPHONE: (510) 725-7919
Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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Document Has Been Signed on 02/11/2025 02:39 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2025
Section Cited
CCR
87211(a)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement is not met as evidence by:
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Administrator agreed to read the regulation and conduct an In-Service training with staff on reporting requirements. Submit training sign-in sheet to CCLD by POC due date.
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Based on interview and record review the licensee did not comply with the section cited above in by notifying CCLD of R1's hospitalization (LIC624) which poses a potential health, safety and personal rights risk to persons 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.
Bennett FongTELEPHONE: (510) 725-7919
Lori Alexander-WashingtonTELEPHONE: (510) 285-3934

DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025

LIC809 (FAS) - (06/04)
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