<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601256
Report Date: 10/12/2022
Date Signed: 10/12/2022 10:14:24 AM

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
01/26/2021 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20210126151403
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: 28DATE:
10/12/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Teresa Truong, AdministratorTIME COMPLETED:
10:25 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to properly dispense a medication resulting in a questionable death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/12/2022 at 9:15AM Licensing Program Analyst (LPA) Jill Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegation. Upon arrival, LPA met with Teresa Truong, Administrator and explained the reason for the visit.

The complaint was received on February 5, 2021. It was alleged that the facility failed to properly dispense a medication resulting in a questionable death.

During the course of the investigation, the Department conducted interviews with staff (S1, S2, S3), hospice nurses (RN1), Clients (R2, R3, R4) and R1’s Doctor. The Department also obtained R1’s documents, as well as R1’s hospice and medical records.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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 2
Control Number 15-AS-20210126151403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/12/2022
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
Statements from the interviews show that R1’s health was declining prior to being given the wrong medication and R1 did not show signs of a reaction to the medication and it is not believed that taking the wrong medication played a part in her death. The death certificate states cause of death was Alzheimer's disease.

Based on all information obtained by the Department, the allegation is UNSUBSTANTIATED. An unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and copy of this report provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2