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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601256
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:41:17 PM


Document Has Been Signed on 08/01/2024 01:41 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WILLOW CREEK ALZHEIMER'S & DEMENTIA CARE CENTERFACILITY NUMBER:
015601256
ADMINISTRATOR:CARSON, ELIZABETH MFACILITY TYPE:
740
ADDRESS:22424 CHARLENE WAYTELEPHONE:
(510) 889-1300
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:49CENSUS: 39DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Elizabeth Carson, AdministratorTIME COMPLETED:
02:25 PM
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On 08/01/2024 at 9:40 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Elizabeth Carson and explained the purpose of the visit.

LPA toured the facility including but not limited to 4 residents’ rooms, bathrooms, two activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 111.5 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 are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/20/2024. Emergency Disaster Plan was last posted on 01/12/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/13/2024.

At 11:34 AM, LPA reviewed 5 staff records and all were complete. At 12:30 PM, LPA reviewed 6 residents records, and all were complete. at 1 PM, LPA reviewed 6 residents medications.

LPA also reviewed and obtained a copy of the following documents: LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance Current Administrator’s Certificate renewal documents.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan GharachorlooTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
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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