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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601363
Report Date: 06/21/2022
Date Signed: 06/21/2022 05:20:23 PM

Document Has Been Signed on 06/21/2022 05:20 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 AT POETS CORNERFACILITY NUMBER:
075601363
ADMINISTRATOR:SARAH CONNOR-KERRFACILITY TYPE:
740
ADDRESS:540 PATTERSON BOULEVARDTELEPHONE:
(925) 287-8750
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 75CENSUS: 42DATE:
06/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:31 PM
MET WITH:Evelyn Valladares, Executive Director and Myrene Gaeta, Resident care director TIME COMPLETED:
05:45 PM
NARRATIVE
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On 6/21/2022 starting at 5:00 PM, Licensing Program Analyst (LPA) L. Ibo conducted unannounced case management visit.

LPA observed the following:

Based on records review S1 and S3 not associated to the facility.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/21/2022 05:20 PM - It Cannot Be Edited


Created By: Leslie Ibo On 06/21/2022 at 04:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CHATEAU AT POETS CORNER
FACILITY NUMBER: 075601363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2022
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record review ..... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
-This requirement is not met as evidenced by:

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Administrator has agreed to associate S1 and S2 to the facility and submit documentation to CCLD by POC date
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-Based on observation, interview and review of record, the licensee did not comply with the above Regulation by not S1 and S3 associated which poses potential 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 Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
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