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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600194
Report Date: 12/11/2023
Date Signed: 12/11/2023 06:47:34 PM


Document Has Been Signed on 12/11/2023 06:47 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: 132DATE:
12/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Tracey Ingleman, Executive DirectorTIME COMPLETED:
05:30 PM
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On 12/11/2023 at 4:30PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit to follow-up on a death report received by Community Care Licensing Division on 11/13/2023. LPA met with Executive Director (ED), Tracey Ingleman and explained the purpose of the visit.

R1 passed away on 11/06/2023 with an unknown cause of death. Death report stated that R1 had an unwitnessed fall on 11/06/23 at 12:30PM. The death report revealed that R1 passed away at the hospital on 11/06/2023.

During today's visit LPA requested additional information pertaining to R1's file which included:
  • Physician's report (LIC602)
  • Appraisal Needs and Services Plan

LPA was informed by ED that R1's family will obtain a copy of R1's death certificate and during the visit the copy was received. The Certificate of Death reveals that cardiopulmonary arrest was the immediate cause of death of R1.

No deficiencies cited during this 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: 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)
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