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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601256
Report Date: 02/04/2021
Date Signed: 02/04/2021 04:25:47 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: 36DATE:
02/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Kelsey GonzalezTIME COMPLETED:
04:16 PM
NARRATIVE
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On 02/04/2021 at 3:15pm Licensing Program Analyst (LPA) Allison O'Hollaren (AO) conducted an unannounced case management visit to perform a health and safety check of the facility, meeting with Administrator Kelsey Gonzalez. Due to the State's current COVID-19 shelter in place order the visit was conducted by tele-visit. An explanation for the purpose of the visit was provided.

A tour of the physical plant was made. Fire extinguishers are working and not expired. Medications are locked. There are no sharp objects out and unlocked. There are no obstructions of emergency exits. Power was operational.

LPA AO observed that cleaning supplies were kept in storage closet and door was unlocked during facility tour.

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: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
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: 02/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2021
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia...toxic substances such as... cleaning supplies and disinfectants. This requirement was not met as
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evidenced by: LPA AO observed toxins in an unlocked closet.
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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: 02/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2021
LIC809 (FAS) - (06/04)
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