Chateau Iii

LIC9099-C (Page 2) Allegation: Resident sustained a broken arm while in care Investigation Finding: Unsubstantiated The Department found that on 10/10/2024, at or around 0555 hours, S1 found R1 on the floor of R1’s kitchenette when conducting an incontinence check. R1 reported that they had gotten up to get something to drink on their own. R1 did not press their pendant to request staff’s help. S1 called the overnight supervisor S2, who responded and assessed R1. R1 complained of pain and injury to their head and left arm. R1 was transported to John Muir Medical Center via ambulance. While in the ambulance, R1 reported that they stood up to try to get a pill and fell landing on their left shoulder and face and was unable to get up. R1 was also found to have a Urinary Tract Infection (UTI). R1 underwent a Computed Tomography (CT) scan, which showed a fracture of the left humeral head, neck, and proximal diaphysis. R1’s face was also bruised on the left side as well as their left shoulder. R1’s responsible party is aware of at least six falls and said most of R1’s falls were due to a history of UTIs. R1 has a wrist pendant that they can press to alert and request staff’s assistance. W1 stated that there are no real fall prevention methods in place for R1 other than frequent checks, escort assistance, and the wrist pendant. Staff interviewed vaguely recalled details of R1’s fall from 10/10/2024, but stated R1 got up on their own and did not press their pendant button to ask staff for help, despite being bed bound and unable to stand up or walk on their own. S2 said a family conference would be held and a resident’s care plan would be amended to add additional services when a resident falls more than three times within a 30-day period. LIC9099-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C (Page 3) The Department reviewed R1’s file and observed that while the MD report indicates R1 to have been a fall risk, there was no documented fall between 2/1/24 and the subject incident of 10/10/24. The records also indicate that from 9/1/24 and 11/30/24, there was 1 fall (the subject incident). The Department found that information obtained was insufficient to confirm that staff had not performed a need which resulted in the fall, injury, and hospitalization. Staff schedule indicates that 6 care staff were on duty at the time of the incident. The Department has investigated this allegation and although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the subject incident was specifically due to neglect. Therefore, the allegation is Unsubstantiated. Allegation: Facility failed to provide adequate care to resident Investigation Finding: Unsubstantiated The Department reviewed documentation indicating that R1 has sustained 16 falls at the facility since their admission in 2022. One Unusual Incident Report, dated 10/10/24, indicated that a caregiver found R1 on the floor in their room during an incontinence check. R1 complained of head and left arm pain/injury. Staff #3 (S3) contacted Staff #4 (S4), who then called 911. No other incidents were documented between 09/01/24 and 11/30/24. A review of R1’s Physician’s Report (dated 12/21/23) and Bi-Annual Assessment, (dated 12/03/24), indicates that R1 diagnosis is sepsis due to Urinary Tract Infection (UTI), has a history of frequent falls, history of Cerebral Vascular Accident (CVA) LIC9099-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C (Page 4) and utilizes multiple assistive devices, including glasses, half bed rails, hospital bed, pendant, raised toilet seat, shower bench, walker, and wheelchair. R1 cannot ambulate without assistance and requires staff to escort them for 30 minutes per day due to concerns regarding balance and gait. Records further note that R1 has sustained two or more falls within the past year, has expressed fear of falling, and has sustained injuries as a result of previous falls. It was also documented that R1 was not participating in the “Safely You Fall Monitoring Program.” Since admission on 04/22/22, R1 has sustained a total of 16 falls: five in 2022, seven in 2023, three in 2024, and one in 2025. On 11/18/25, record review and interviews with S1 and S2 confirmed that R1 was identified as a fall risk at admission. S1 stated that the community protocol requires a discussion with the resident’s responsible party if three falls occur within a 30-day period. S1 reported that R1’s falls did not meet this threshold, as they occurred sporadically. S1 further stated that staff implemented alert charting, full assessments, and hourly checks for R1. Safely You was offered to the responsible party, who declined participation. S1 also stated that R1’s current care plan includes “Full Care” for ADLs, medication management, continence care, and escort services. LIC9099-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C (Page 5) Based on records review, interviews conducted, and observations made, the Department has investigated the above allegations of “Resident sustained a broken arm while in care” and “Facility failed to provide adequate care to resident” to be unsubstantiated. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations of Resident sustained a broken arm while in care and Facility failed to provide adequate care to resident is Unsubstantiated . Exit interview conducted and a copy of this report provided.

On 08/06/2025 at 2:00 PM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a 1-Year Annual Required inspection. LPAs met with the Director of Residents Services (DRS), Sheila Roberts, and explained the purpose of the visit. Executive Director (ED), Tracey Ingleman, arrived approximately 30 minutes late. The facility’s fire clearance was approved for capacity of 175 residents all may be non-ambulatory. Hospice waiver for fourteen (14) residents. Bedridden fire clearance for six (6) on first floor only. Administrator Certificate # 6029374740 (renew on: 6/9/2025). LPA toured the facility with Tracey Ingleman ED and Sheila Roberts including but not limited to five (5) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms is adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70- and 74-degrees F. The hot water temperature in a sample resident’s bathroom was measured at an average of 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharp and toxic chemicals are locked and inaccessible to residents in care. Fire Drill last conducted on June 11, 2025, and June 18, 2025, Maintenance on 1 bus( Registration from 6/30/2025 to 6/30/2026) and 1 wheelchair van updated(Registration 5/31/2025 to 5/31/2026). Emergency Disaster Plan last updated on 6/13/2025. Liability Insurance effective date: 7/1/2024 to 7/1 2026. The fire extinguisher last inspected 3/13/2025. LIC809-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA reviewed ten (10) residents records. LPA reviewed nine (9) staff records and 9 of 9 have current first aid training and are associated with the facility. Updated copies of the following documents were requested for facility file and are reviewed on 8/6/2025: LIC 308 Designation of Administrative Responsibility- Reviewed LIC 309 Administrative Organization- Reviewed LIC 500 Personnel Report- Reviewed LIC 610E Emergency Disaster Plan (with last page dated and signed)- Reviewed Copy of Liability Insurance- Reviewed No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.

On 08/29/2024 at 11:45 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Director of Residents Services (DRS), Sheila Roberts and explained the purpose of the visit. Executive Director (ED), Tracey Ingleman, arrived approximately 30 minutes later. The facility’s fire clearance was approved for capacity of 175 residents all may be non-ambulatory. Hospice waiver for fourteen (14) residents. Bedridden fire clearance for six (6) on first floor only. Administrator Certificate # 6029374740 Expires 07/07/2025. LPA toured the facility with ED including but not limited to five (5) residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 and 74 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 107.1, 109.0, 104.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic chemicals are locked and inaccessible to residents in care. Maintenance on six (6) buses and wheelchair vans updated. LPA reviewed eight (8) residents records. LPA reviewed nine (9) staff records and 9 of 9 have current first aid training and associated to the facility. LIC809-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC809-C Continued... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/05/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (with last page dated and signed) Copy of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 12/11/2023 at 4:30PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit to follow-up on a death report received by Community Care Licensing Division on 11/13/2023. LPA met with Executive Director (ED), Tracey Ingleman and explained the purpose of the visit. R1 passed away on 11/06/2023 with an unknown cause of death. Death report stated that R1 had an unwitnessed fall on 11/06/23 at 12:30PM. The death report revealed that R1 passed away at the hospital on 11/06/2023. During today's visit LPA requested additional information pertaining to R1's file which included: Physician's report (LIC602) Appraisal Needs and Services Plan LPA was informed by ED that R1's family will obtain a copy of R1's death certificate and during the visit the copy was received. The Certificate of Death reveals that cardiopulmonary arrest was the immediate cause of death of R1. No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.

On 12/11/2023 at 3:30PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit to follow-up on the Covid Positive cases reported to Community Care Licensing Division on 11/01, 11/07, 11/27, 11/30 and 12/06. LPA met with Executive Director (ED), Tracey Ingleman and explained the purpose of the visit. ED says they are in contact with the Contra Costa Public Health (CCPH) and have been advised by CCPH to test residents and staff every week until 2 weeks past of no positive test results. ED states that the recommendations from CCPH is that staff continues to wear masks, visitors don't have to wear a mask. Residents (assisted living) that are positive are to quarantine in their apartments for 7 days. There are no dining room restrictions (i.e., dining room closures). Staff (caregivers) are to wear PPE (gowns, N-95 masks, gloves) when they enter a Covid positive resident's room. ED states that they have signage posted outside the doors with carts that include PPE as well as the storage to down and remove PPE. ED stated that residents located in memory care are to also quarantine for 7 days but the residents tend to wander and therefore it is really difficult to isolate the residents. LIC809-C Continued... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC809 Continued.... ED states that staff that test positive are to quarantine for 5 days and after having no symptoms and test negative the staff can return back to work. Staff that return after 5 days quarantine will have to wear a N-95 mask for 5 more additional days. No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.

On 12/11/2023 at 5:30PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 11/30/2023. LPA met with Executive Director, Tracey Ingleman, and explained the purpose of the visit. LPA interviewed S2 to get further details of the incident. S2 stated that the family contacted the facility and informed after reviewing their mother's bank account that they saw a check cashed for $3000.00. S2 further states that she received a text message from R1's son with an image of the cashed check of $3000.00. S2 stated that the person's name endorsed on the check was one of her staff (S1). S2 stated that she contacted Pleasant Hill PD and spoke with an officer in which they both collaborated when S1 would be back at work and the officer would come to the facility to speak to S1. On 11/30/23 S1 arrived at the facility for a staff training from 9pm to 10pm. S2 stated that she went to the training room to get S1 after the police arrived at the facility approx. 9:45pm. S2 stated that the officer spoke with S1 and made an arrest. LIC809-C Continued.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC809 Continued.... LPA collected documents pertinent to the incident report. Documents received: 1. an email from S3 2. a copy of text message received from S2 3. a copy of the cashed check 4. a copy of S1's Hire Form, Application Report, Form I-9 with attached copies of Social Security Card and USA Permanent Resident Card 5. Pleasant Hill Police Report #23-3842 No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

On 9/13/2023 at 10:00am, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Vicki Vasconi, Resident Liason. Executive Director, Tracy Ingleman, arrived at 10:15am and explained the purpose of the visit. The facility’s fire clearance was approved for 169 non-ambulatory and 6 bedridden residents. LPAs toured the facility with Tracey including but not limited to 8 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F in independent living and 75 degrees F in memory care areas. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature measured at 138 degrees Fahrenheit in the front lobby area. Residents’ bathrooms are equipped with grab bars and non-skid shower floors. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/09/2023. Emergency Disaster Drill was last posted on 07/21/2023. First aid kit was observed to be complete. Fire drill was last conducted on 08/11/2023. Continued on LIC809C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809C. LPAs reviewed ten (10) residents records all are current and complete. LPAs reviewed eleven (11) staff records all have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/20/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

(a) Continued from LIC9099. two (2) hours during the day and every three (3) hours in the early morning. Based on the investigation the above allegations are substantiated. Resident became severely dehydrated in facility . Reporting Party (RP) reported Resident became severely dehydrated in facility. Based on record review of facility’s incident report Resident 2 (R2) was transported to the hospital on 12/25/2019 and discharged on 12/29/2019. Discharge summary report from the hospital did not indicate that R2 was dehydrated, but R2 did have an unspecified infection pending lab results. Staff did not administer resident’s medications per physician’s order . RP stated that R1 was prescribed medication and the facility stopped administering the medication which sent R1 back to the hospital. Based on record review and interview the medication for resident was discontinued on 5/05/2020. S2 stated during interview that staff faxed R1’s doctor on 5/23/2020 to confirm medication had stopped because R1 had been in and out of the hospital and there were a lot of changes. S2 also stated that R1 was given two (2) prescriptions for same medication and both were stopped. Staff did not obtain timely medical care for resident RP reported the doctor had requested R1 to return to the hospital after R1 had called the doctor and the facility resisted to call 9-1-1 until two (2) to three (3) hours later. During record review LPA observed facility's incident report dated 5/10/2020 at 7:30PM, indicated R1 was assessed by staff and staff contacted advice nurse. Continued on LIC9099C (b). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (b) Continued from LIC9099C. Advice nurse stated the doctor requested R1 to be admitted and 9-1-1 was called. Although time may have elapsed before the facility called 9-1-1, the facility had to follow protocol, therefore the facility did obtain medical treatment in a timely manner. Facility charged resident for services that were not provided RP stated that facility was charging R1 and R2 an escorting fee during facility’s COVID lockdown, and R1 an dressing assistance fee even though he was not getting dressed. During interview with S1 it was stated that the facility did continue the escorting and dressing assistance charges. S1 stated the facility staff continued getting the residents dressed during the lockdown unless the resident refused. S1 also stated even though the residents were isolated in the room the escorting fee was still being charged to the residents that had previously been receiving escort services, but none of the residents were being charged tray service to their rooms. During record review LPA observed a memo dated 3/13/2020 which stated the facility strongly encourage residents to opt for complimentary room service due to dining room restrictions. LPA also observed that R1 and R2 had completed escorting assistance three times daily before lockdown, and that the facility was in a sustained COVID surge from April 2020 until November 2020. Staff failed to properly maintain resident's room. RP stated the hired private caregiver stated that on the first day of employment R2’s room was dark, on a Spanish channel and the cat’s care needed attention. There were no other days mentioned about the room or the cat. Based on record review of Continued on LIC9099C (c). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (c) Continued from LIC9099C. R2, individual service plan dated 1/16/2020, R2 was receiving pet assistance care twice a day and daily bed making. Staff did not provide proper care for resident. RP stated that R2 was bathed or had a sponge bath once in a while, and her teeth not cleaned every day. Record review indicated that R2 was receiving AM and PM grooming assistance, and bathing assistance one (1) day a week. Review of summary of services provided by facility explains services, how many days, how much time, and the price of the service. S1 stated the additional personal services are agreed upon after the resident have been admitted into the facility and an individual service plan have been completed. S1 stated that sometimes the individual service plan must be revisited and updated but the new plan is discussed with the residents’ responsible party, and if a residents’ responsible party request more days or times to a service a new individual service plan is created and signed . Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of this report provided.

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.

On 08/31/2022 at 11:55 AM, Licensing Program Analysts (LPAs) C. Fowler and L. Alexander arrived unannounced to conduct 1-Year Infection Control Inspection. LPAs met with Executive Director, Tracy Ingleman and Director of Residence Service Sheila Roberts and explained the purpose of the visit. The facility’s fire clearance was approved for 175 Residents. LPAs toured the facility with ED and DRS including but not limited to 3 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in residents’ shared bathroom were measured at 109.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 days supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/07/2022: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Continue on LIC809C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809 Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided

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.

Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator TRACEY INGLEMAN . LPA observed all staff wearing face masks during the visit. The Department did not have a copy of their 01/20/2021 mitigation plan, so the LPA reviewed and approved it and then uploaded it to FAS. Ms. Ingleman is the Infection control designated leader. LPA discussed the mitigation plan with administrator, as well as their current COVID-19 infection control practices. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. All but 4 staff and 2 residents were fully vaccinated. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with a digital visitor's log, hand sanitizer, face masks, and a no-touch temperature probe. Routine symptom screening (+/-) temperature and symptom check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents electronically. Pathways were observed to be free of obstruction and fire hazards. There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper and PPE supplies were observed. Facility room temperature was maintained at a comfortable temperature. A certified administrator is on site at all times to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and last inspected on 09/1/21. Smoke and Carbon monoxide detectors were operational. LPA observed the facility is in substantial compliance. No deficiencies are being cited during this inspection. Exit interview conducted and a copy of this report provided.