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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600194
Report Date: 09/30/2021
Date Signed: 09/30/2021 03:27:16 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: 134DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:TRACEY INGLEMANTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator TRACEY INGLEMAN. LPA observed all staff wearing face masks during the visit. The Department did not have a copy of their 01/20/2021 mitigation plan, so the LPA reviewed and approved it and then uploaded it to FAS.

Ms. Ingleman is the Infection control designated leader. LPA discussed the mitigation plan with administrator, as well as their current COVID-19 infection control practices. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. All but 4 staff and 2 residents were fully vaccinated.

LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with a digital visitor's log, hand sanitizer, face masks, and a no-touch temperature probe. Routine symptom screening (+/-) temperature and symptom check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents electronically.

Pathways were observed to be free of obstruction and fire hazards. There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper and PPE supplies were observed. Facility room temperature was maintained at a comfortable temperature. A certified administrator is on site at all times to oversee proper business operation and compliance with COVID-19 infection control practices.

Fire extinguishers were observed fully charged and last inspected on 09/1/21. Smoke and Carbon monoxide detectors were operational.

LPA observed the facility is in substantial compliance. No deficiencies are being cited during this inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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