015601256-5-16-2025-15-AS-KHOS-DHQSUP-20250617141127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601256
Report Date: 05/16/2025
Date Signed: 05/16/2025 03:45:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
08/26/2024 and conducted by Evaluator Ardalan Gharachorloo

COMPLAINT CONTROL NUMBER: 15-AS-20240826155302

FACILITY NAME:	WILLOW CREEK ALZHEIMER'S & DEMENTIA CARE CENTER		FACILITY NUMBER:	015601256
ADMINISTRATOR:	CARSON, ELIZABETH M		FACILITY TYPE:	740
ADDRESS:	22424 CHARLENE WAY		TELEPHONE:	(510) 889-1300
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	49	CENSUS: 30	DATE:	05/16/2025
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Elizabeth Carson, VP of Operations		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained unexplained injury while in care.
Facility staff did not seek medical attention of residents in care.

INVESTIGATION FINDINGS:

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On 05/16/2025 at 2:10 PM, Licensing Program Analysts (LPAs) Ardalan Gharachorloo and Greg Clark arrived unannounced to deliver findings in regard to the allegations above. LPAs met with VP of Operations, Elizabeth Carson and explained the purpose of the visit.

During the course of the investigation LPsA interviewed W1, S1-S5 and toured the facility’s memory care unit and reveiwed documents related to R1's care. LPA was unable to interview because R1 no longers lives at the facility.

Allegation : Resident sustained unexplained injury while in care

On 08/21/2024, staff observed that R1 had a small bruise on the left lower outer eye area around 12:00 PM. LPA interviewed S1-S5 who confirmed that the Administrator, Resident Care Coordinator, and Primary Care Physician were notified the same day. A skin check was conducted, and no other injuries were found. The resident, who is bedridden and has Alzheimer’s, denied pain, and staff reported no signs of distress.

***CONTINUE ON PAGE 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan Gharachorloo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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 3

Control Number 15-AS-20240826155302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CENTER	FACILITY NUMBER: 015601256
	VISIT DATE: 05/16/2025

NARRATIVE

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***CONTINUE FROM 9099***

The facility reviewed video surveillance showing only staff entered R1’s room during the time frame of 6:30 AM to 12:00 PM. The internal investigation concluded the injury may have been caused by either R1's long fingernails or accidental contact with hospital bed rails during repositioning. A corresponding Unusual Incident Report for the injury was submitted to CCL.

LPA interviewed W1 who stated that when she visited R1 on 08/24/2024 and observed what appeared to be a full black eye, not a minor bruise. W1 took photographs and contacted facility staff, but no additional explanation was provided at that time. W1 also contacted Kaiser, which led to a welfare check by the Alameda County Sheriff’s Office on 08/24/2024. It was reported that the officer interviewed R1 and staff but did not report any findings. W1 stated in written communication that no incident report was initially shared with them and that the description of the injury appeared inconsistent with what they observed in person.

Allegation : Facility staff did not seek medical attention for resident in care

LPA interviewed S1-S5 who confirmed that the resident’s physician was notified the same day via faxed. There is no indication in the facility's records that an in-person physician visit was ordered or conducted. Facility records indicate that the resident was assessed for additional injuries, found to be stable, and showed no signs of pain or discomfort. The resident’s care plan was reassessed, and follow-up action was taken, including changes to repositioning protocol and equipment.

LPA interviewed W1 who reported that after observing the injury on 08/24/2024, they contacted Kaiser to request medical evaluation for R1 but W1 did not want R1 to go to Kaiser. W1 worried that if R1 went to the hospital she would be exposed to Covid. Kaiser requested Alameda County Sheriff’s Department to perform a welfare check. Documentation submitted by W1 includes photographs of R1’s injury and email communications expressing concern that no physical medical evaluation had occurred and that no clear explanation of the injury was available. Interviews with facility staff revealed that R1 received proper medical evaluation for her injury.

***CONTINUE ON 9099C***

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan Gharachorloo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20240826155302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CENTER	FACILITY NUMBER: 015601256
	VISIT DATE: 05/16/2025

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	*CONTINUE FROM 9099C* This agency has investigated the above allegations. We have found that the complaint was unsubstantiated. Although the allegations 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 allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan Gharachorloo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3