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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 06:46:32 PM


Document Has Been Signed on 12/11/2023 06:46 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 - Infectious Disease OutbreakUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Tracey Ingleman, Executive DirectorTIME COMPLETED:
04:30 PM
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On 12/11/2023 at 3:30PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit to follow-up on the Covid Positive cases reported to Community Care Licensing Division on 11/01, 11/07, 11/27, 11/30 and 12/06. LPA met with Executive Director (ED), Tracey Ingleman and explained the purpose of the visit.

ED says they are in contact with the Contra Costa Public Health (CCPH) and have been advised by CCPH to test residents and staff every week until 2 weeks past of no positive test results. ED states that the recommendations from CCPH is that staff continues to wear masks, visitors don't have to wear a mask. Residents (assisted living) that are positive are to quarantine in their apartments for 7 days. There are no dining room restrictions (i.e., dining room closures). Staff (caregivers) are to wear PPE (gowns, N-95 masks, gloves) when they enter a Covid positive resident's room. ED states that they have signage posted outside the doors with carts that include PPE as well as the storage to down and remove PPE.

ED stated that residents located in memory care are to also quarantine for 7 days but the residents tend to wander and therefore it is really difficult to isolate the residents.


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
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LIC809 Continued....

ED states that staff that test positive are to quarantine for 5 days and after having no symptoms and test negative the staff can return back to work. Staff that return after 5 days quarantine will have to wear a N-95 mask for 5 more additional days.

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
LIC809 (FAS) - (06/04)
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