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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600194
Report Date: 09/13/2023
Date Signed: 09/13/2023 02:26:44 PM


Document Has Been Signed on 09/13/2023 02:26 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 IIIFACILITY NUMBER:
075600194
ADMINISTRATOR:TRACEY INGLEMANFACILITY TYPE:
740
ADDRESS:175 CLEAVELAND ROADTELEPHONE:
(925) 935-1001
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:175CENSUS: 137DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vicki Vasconi, Resident LiasonTIME COMPLETED:
02:40 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 9/13/2023 at 10:00am, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Vicki Vasconi, Resident Liason. Executive Director, Tracy Ingleman, arrived at 10:15am and explained the purpose of the visit. The facility’s fire clearance was approved for 169 non-ambulatory and 6 bedridden residents.

LPAs toured the facility with Tracey including but not limited to 8 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F in independent living and 75 degrees F in memory care areas. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature measured at 138 degrees Fahrenheit in the front lobby area. Residents’ bathrooms are equipped with grab bars and non-skid shower floors. 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.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/09/2023. Emergency Disaster Drill was last posted on 07/21/2023. First aid kit was observed to be complete. Fire drill was last conducted on 08/11/2023.

Continued on LIC809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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 3


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 III
FACILITY NUMBER: 075600194
VISIT DATE: 09/13/2023
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
26
27
28
29
30
31
32
Continued from LIC809C.

LPAs reviewed ten (10) residents records all are current and complete. LPAs reviewed eleven (11) staff records all have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/20/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

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: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3