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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600194
Report Date: 02/11/2022
Date Signed: 02/11/2022 05:00:49 PM


Document Has Been Signed on 02/11/2022 05:00 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
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: 125DATE:
02/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Tracey InglemanTIME COMPLETED:
05:15 PM
NARRATIVE
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On 2/11/22 at 2:45 PM, Licensing Program Analysts (LPAs) Jill Clancy-Czuleger and Lizette Francisco arrived unannounced to conduct a Case Management to follow-up on an incident report submitted to CCL on 1/21/2022. LPAs met with Executive Director and explained the purpose of the visit.

Based on incident report, facility had a COVID-19 outbreak on 1/05/2022. However, incident report was not submitted to licensing until 1/21/2022. On 1/27/2022 and 2/8/2022, LPA J. Clancy-Czuleger was notified of new positive cases. However, facility did not report to LPA within 24 hours of occurrence via phone call.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal rights and a copy of this reporat provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022
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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Document Has Been Signed on 02/11/2022 05:00 PM - It Cannot Be Edited

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: 02/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/14/2022
Section Cited

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Reporting Requirements
(2) Occurrences, such as epidemic outbreaks... shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate

This requirement is not met by evidenced by
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Administrator agrees to review regulation and conduct in-service training with staff on reporting requirements and submit a copy of training with signatures to CCL by POC date.
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Based on record review and observation licensee did not comply with the regulation cited above. Facility did not contact licensing within 24 hours of outbreak which poses an immediate health and safety risk for persons in care.
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Request Denied
Type B
02/18/2022
Section Cited

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Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ...


This requirement is not met by evidenced by
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Administrator agrees to review regulation and conduct in-service training with staff on reporting requirements and submit a copy of training to CCL by POC date.
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Based on record review, licensee did not comply with the regulation cited above. Incident report was submitted to licensing on 1/21/2022. However, incident occurred on 1/5/2022 which poses a potential health and safety risk to persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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