075600194-8-30-2022-15-AS-KHOS-CHTKWK-20220831081606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600194
Report Date: 06/18/2021
Date Signed: 08/30/2022 02:22:48 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/11/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210611114701

FACILITY NAME:	CHATEAU III		FACILITY NUMBER:	075600194
ADMINISTRATOR:	TRACEY INGLEMAN		FACILITY TYPE:	740
ADDRESS:	175 CLEAVELAND ROAD		TELEPHONE:	(925) 935-1001
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	175	CENSUS: 127	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Tracey Ingleman		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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9

Facility's exit alarm on doors is not functioning properly.

INVESTIGATION FINDINGS:

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13

***THIS IS AN AMENDED REPORT FROM VISIT ON 6/18/2021***

On 6/18/2021 starting at 8:50am, Licensing Program Analysts (LPAs) L. Francisco and C.Fowler arrived unannounced to conduct complaint investigation for the above allegation. Upon arrival LPAs were greeted by front desk. Executive Director, Tracey Ingleman later arrived at 9:15am.

Based on record review and interview with staff (S1), resident (R1) left facility and exited through one of the exit doors facing the main parking lot on June 9, 2021. Once staff were made aware of resident's whereabouts, staff determined exit door had malfunctioned and was not operating correctly.

Based on LPAs interview which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/11/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20210611114701

FACILITY NAME:	CHATEAU III		FACILITY NUMBER:	075600194
ADMINISTRATOR:	TRACEY INGLEMAN		FACILITY TYPE:	740
ADDRESS:	175 CLEAVELAND ROAD		TELEPHONE:	(925) 935-1001
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	175	CENSUS: 127	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Tracey Ingleman,		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not react timely during resident's AWOL.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/18/2021 starting at 8:50am, Licensing Program Analysts (LPAs) L. Francisco and Carol Fowler arrived unannounced to conduct complaint investigation for the above allegations. Upon arrival LPAs were greeted by front desk. Executive Director, Tracey Ingleman later arrived at 9:15am.

Based on information obtained, staff did not react timely during resident's AWOL. S1 stated staff were unaware that the exit door had malfunctioned and was not working properly. However, once staff were aware of resident's AWOL, the facility conducted a search at the facility and surrounding neighborhood. S1 stated as S1 attempted to contact local law enforcement, facility was contacted by County Hospital.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210611114701

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/21/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility....and in good repair at all times....procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has implemented daily testing of wander guard doors. LPAs observed alarm on exit door was properly operating during visit. DEFICIENCY CLEARED
	8 9 10 11 12 13 14	Based on record review and interview, Licensee did not comply with the regulation cited above. Alarm on exit door had malfunctioned on 6/9/21 which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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