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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601363
Report Date: 06/18/2020
Date Signed: 06/18/2020 03:37:42 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 AT POETS CORNERFACILITY NUMBER:
075601363
ADMINISTRATOR:MICHELLE GAILEYFACILITY TYPE:
740
ADDRESS:540 PATTERSON BOULEVARDTELEPHONE:
(925) 287-8750
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:75CENSUS: 52DATE:
06/18/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Sarah Conner, Associate DirectorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Praveen Singh conducted an unannounced Case Management inspection to follow-up on a death report received on 6/18/2020. This inspection was conducted via video-conference due to the present shelter in place order by the Governor.

It was reported that R1 had a fall and was sent to the hospital on 6/16/2020. R1 later passed away at the hospital. LPA was informed during tele-inspection that R1 had some underlying health issues, however details surrounding the cause of death were still pending. A Coroner's Report will be sent to LPA upon receipt. In addition, LPA requested a copy of R1's Physician's Report and Needs and Services Plan due no later than COB on 6/19/2020.

During the tele-inspection, LPA also conducted a health and safety inspection with Associate Director Sarah Conner. LPA toured the facility, including but not limited to the kitchen, dining hall, living space, and outside areas. LPA met with dining room supervisor and observed a sufficient supply of perishable and non-perishable foods. LPA observed point of entry for all visitors and observed entry protocol and materials for Covid-19 screening. LPA observed passageways appeared to be free of obstruction. LPA was informed that everything was in good repair and no disruption to utilities.

No deficiencies cited during inspection. Exit interview conducted and a copy of the report emailed to Administrator and Associate Director.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020
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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