015601256-7-1-2022-15-AS-KHOS-CJVKHL-20221004075518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601256
Report Date: 07/01/2022
Date Signed: 07/01/2022 04:39:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/20/2022 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20220620150026

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: 33	DATE:	07/01/2022
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Rohini Chand, Resident Coordinator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Facility staff lack proper understanding of medication procedures.

INVESTIGATION FINDINGS:

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On 7/1/2022 at 3:50PM Licensing Program Analysts (LPAs) K. Nguyen, and L. Francisco arrived unannounced to continue the investigation on the above allegations. LPAs met with Resident Coordinator, Rohini Chand and explained the purpose of visit. LPAs spoke to administrator over the phone.

During the course of the investigation, LPAs obtained information, reviewed records, collected documents, and interviewed 3 staff. Based on information obtained, it was alleged facility staff lack proper understanding of medication procedures. However, LPAs reviewed training records for 6 staff and 6 of 6 are current with their medication training. LPAs interviewed 3 staff and 3 of 3 were able to demonstrate the facility's medication procedures. No additional information forthcoming from complainant therefore LPAs were unable to obtain additional information.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Resident Coordinator. A copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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