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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600194
Report Date: 09/01/2022
Date Signed: 09/01/2022 04:45:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
08/25/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220825093347
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: 123DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tracey Ingleman, Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not properly assess resident's health conditions.
INVESTIGATION FINDINGS:
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On 9/1/2022 at 1:45 p.m., Licensing Program Analysts (LPAs) C. Lin and L. Alexander conducted an unannounced 10-day initial complaint investigation regarding the above allegation and respect to deliver investigation findings. LPAs explained the purpose of the visit with Executive Director (ED).

Allegation: Facility did not properly assess resident's health conditions – Unsubstantiated.
The Department has investigated this allegation, per records review and interviews, and found that individual’s proper paperwork was obtained and reviewed to determine individual’s needs couldn’t be met due to staffing issue in the subjected time period. ED also communicated with individual’s health professional before making decision. In addition, the individual has never been a resident in facility. After reviewing current resident’s record, guest registration, signed physician’s report, and pre-admission assessment forms were observed on file.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20220825093347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/01/2022
NARRATIVE
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Based on records reviewed and interview conducted, the above allegation is unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

No deficiency cited, exit interview conducted with ED, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2