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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601256
Report Date: 09/14/2021
Date Signed: 09/15/2021 09:34:44 AM

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:CARSON, ELIZABETH MFACILITY TYPE:
740
ADDRESS:22424 CHARLENE WAYTELEPHONE:
(510) 889-1300
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:49CENSUS: 37DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Teresa TruongTIME COMPLETED:
02:10 PM
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On 09/14/2021 at 1:11pm, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Teresa Truong and explained the purpose of the visit.

During the inspection, LPA toured facility including but not limited to common areas, bathrooms, dining room, kitchen and backyards. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed PPE, food and paper supplies are sufficient. COVID-19 screening questions were maintained at the facility for all staff, residents, and visitors at entry. Hand sanitizer is provided at facility entrance. Commonly touched surfaces are disinfected 2-3 times a day.

During record review, LPA observed facility has a copy of Mitigation Plan on file.

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: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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