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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600194
Report Date: 12/15/2020
Date Signed: 12/15/2020 03:47:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CHATEAU IIIFACILITY NUMBER:
075600194
ADMINISTRATOR:TRACEY INGLEMANFACILITY TYPE:
740
ADDRESS:175 CLEAVELAND ROADTELEPHONE:
(925) 935-1001
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:175CENSUS: 117DATE:
12/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tracey Ingleman, Executive DirectorTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Executive Director Tracey Ingleman (ED). Due to the present shelter in place order by the Governor, this inspection was conducted via phone conference.

It was self reported to Community Care Licensing (CCL) that on 11/25/2020, S1 was caught on video punching R1. Facility staff immediately notified the Police Department, CCL and the local Ombudsman's office. S1 was subsequently arrested for elder abuse. R1's family declined to take R1 to the hospital and staff assessed R1 for any injuries.

During today's inspection, LPA discussed the incident in detail with ED. On 11/25/2020, multiple staff witnessed S1 punch R1 two times. Staff immediately notified management team who reviewed surveillance footage which confirmed that S1 did indeed punch R1. Per ED's instructions, staff immediately contacted the Pleasant Hill Police Department who right away came out to the facility and after conducting interviews and reviewing video footage, arrested S1. ED estimates that it took approximately an hour and half from the time the incident occurred to the time the arrest was made. When EMTs came to the facility, they assessed R1 for any injuries and concluded that there were no apparent injuries. Facility Nurse and staff monitored R1 for three days and did not observe any delayed injuries.

No deficiencies cited during today's inspection. Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020
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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