<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601256
Report Date: 08/20/2020
Date Signed: 08/20/2020 12:00:36 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/21/2020 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200521165123
FACILITY NAME:WILLOW CREEK ALZHEIMER'S & DEMENTIA CARE CENTERFACILITY NUMBER:
015601256
ADMINISTRATOR:KELSEY GONZALEZFACILITY TYPE:
740
ADDRESS:22424 CHARLENE WAYTELEPHONE:
(510) 889-1300
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:49CENSUS: 39DATE:
08/20/2020
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Kelsey Gonzalez, AdministratorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unlawful eviction.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/20/2020 at 11:25am, Licensing Program Analyst, L. Hall had an unannounced tele-visit via facetime to deliver the findings on the allegation of “unlawful eviction”. LPA spoke with Kelsey Gonzales, Administrator and explained the reason for the tele-visit.

During the course of the investigation, LPA conducted interviews with staff, the witness, and collected and reviewed documentation. Based on interviews conducted and review of documentation in relation to R1, it was determined that R1 was never being evicted. W1 stated that R1 stayed in the hospital an additional week for unknown reason. Per documentation on 05/10/2020 R1 had a medical condition that was contagious and S1 requested documentation that R1 was cleared from that medical condition. After S1 received documentation on 05/22/2020 that R1 was cleared, R1 returned to the facility on 05/23/2020.
Continued on LIC9099C.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
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-20200521165123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WILLOW CREEK ALZHEIMER'S & DEMENTIA CARE CENTER
FACILITY NUMBER: 015601256
VISIT DATE: 08/20/2020
NARRATIVE
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 LIC9099.

Based on the information obtained the allegation is closed as UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Kelsey Gonzalez, Administrator and a copy will be emailed
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2