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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601256
Report Date: 01/20/2021
Date Signed: 01/20/2021 03:13:37 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: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: 34DATE:
01/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Kelsey GonzalezTIME COMPLETED:
03:00 PM
NARRATIVE
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On 01/20/2021 at 2:15pm Licensing Program Analyst (LPA) Allison O'Hollaren conducted an unannounced Case Management visit meeting regarding an incident that was reported to CCLD on 01/13/2021. LPA spoke with Kelsey Gonzalez, Administrator and explained the purpose of the phone call.

During the phone call LPA spoke and reviewed incident with Administrator. Administrator confirmed that R1 was incorrectly given two vitamins and one medication that belonged to another resident on 01/12/2021. The error was discovered immediately after.


The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

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



SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021
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
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: WILLOW CREEK ALZHEIMER'S & DEMENTIA CARE CENTER
FACILITY NUMBER: 015601256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2021
Section Cited

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87465 (c) If the resident's physician has stated in writing... facility staff designated ... provided all of the following requirements are met: (2) Once ordered...the medication is given according to the physician's directions.
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This requirement was not met as evidencenced by:
Based on LPA interview Licensee did not comply with the regulaton stated above which poses a potential health and safety risk to the resident.
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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: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2021
LIC809 (FAS) - (06/04)
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