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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600194
Report Date: 08/29/2024
Date Signed: 08/29/2024 04:24:10 PM


Document Has Been Signed on 08/29/2024 04:24 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: 139DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tracey Ingleman, Executive DirectorTIME COMPLETED:
04:40 PM
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On 08/29/2024 at 11:45 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Director of Residents Services (DRS), Sheila Roberts and explained the purpose of the visit. Executive Director (ED), Tracey Ingleman, arrived approximately 30 minutes later. The facility’s fire clearance was approved for capacity of 175 residents all may be non-ambulatory. Hospice waiver for fourteen (14) residents. Bedridden fire clearance for six (6) on first floor only. Administrator Certificate # 6029374740 Expires 07/07/2025.

LPA toured the facility with ED including but not limited to five (5) residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 and 74 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 107.1, 109.0, 104.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic chemicals are locked and inaccessible to residents in care. Maintenance on six (6) buses and wheelchair vans updated.

LPA reviewed eight (8) residents records. LPA reviewed nine (9) staff records and 9 of 9 have current first aid training and associated to the facility.

LIC809-C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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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: 08/29/2024
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LIC809-C Continued...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/05/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (with last page dated and signed)
Copy of Liability Insurance

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: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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