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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600194
Report Date: 03/04/2021
Date Signed: 03/04/2021 05:18:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 119DATE:
03/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Tracey Ingleman, Executive DirectorTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-inspection with Executive Director Tracey Ingleman (ED). Due to the present shelter in place order by the Governor, this inspection was conducted via video conference.

It was self reported to Community Care Licensing (CCL) that facility staff reviewed surveillance footage showing S1 slapping R1 on 2/26/21. Facility staff notified the Police Department, CCL, R1's family and the local Ombudsman's office.

During today's inspection, LPA discussed the incident with ED. On 3/1/21, ED was conducting quality control surveillance footage review of S1's transferring technique of residents. In the process of this review, ED observed an incident wherein S1 appeared to slap R1 on the upper back after R1 bumped into S1.
R1 was evaluated for any injuries and placed on alert charting. Facility nurse concluded there were no apparent injuries from the incident. S1 was suspended on 3/1/21 and formally terminated the next day. All staff are scheduled to be retrained in Dementia care, sensitivity and abuse by the end of the month.

The following deficiency is cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted and a copy of the report and Appeal Rights provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CHATEAU III
FACILITY NUMBER: 075600194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2021
Section Cited

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(a)(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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This requirement is not met as evidenced by licensee's failure to prevent resident abuse which poses a potential health and safety risk to the residents.

On 2/26/21, S1 was seen on video footage slapping R1 on the upper back.
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Proof of training will be sent to LPA Singh via email by POC date.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2021
LIC809 (FAS) - (06/04)
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