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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600194
Report Date: 12/11/2023
Date Signed: 12/11/2023 06:48:55 PM


Document Has Been Signed on 12/11/2023 06:48 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: DATE:
12/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Tracey Ingleman, Executive DirectorTIME COMPLETED:
07:10 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 12/11/2023 at 5:30PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 11/30/2023. LPA met with Executive Director, Tracey Ingleman, and explained the purpose of the visit.

LPA interviewed S2 to get further details of the incident. S2 stated that the family contacted the facility and informed after reviewing their mother's bank account that they saw a check cashed for $3000.00. S2 further states that she received a text message from R1's son with an image of the cashed check of $3000.00. S2 stated that the person's name endorsed on the check was one of her staff (S1). S2 stated that she contacted Pleasant Hill PD and spoke with an officer in which they both collaborated when S1 would be back at work and the officer would come to the facility to speak to S1.

On 11/30/23 S1 arrived at the facility for a staff training from 9pm to 10pm. S2 stated that she went to the training room to get S1 after the police arrived at the facility approx. 9:45pm. S2 stated that the officer spoke with S1 and made an arrest.


LIC809-C Continued....
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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 2


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: 12/11/2023
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
LIC809 Continued....

LPA collected documents pertinent to the incident report.

Documents received:

1. an email from S3
2. a copy of text message received from S2
3. a copy of the cashed check
4. a copy of S1's Hire Form, Application Report, Form I-9 with attached copies of Social Security Card and USA Permanent Resident Card
5. Pleasant Hill Police Report #23-3842

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2