015601256-10-12-2022-15-AS-HHUL-CKZW5N-20221109155925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601256
Report Date: 10/12/2022
Date Signed: 10/12/2022 10:13:23 AM

Substantiated

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 CENTER		FACILITY NUMBER:	015601256
ADMINISTRATOR:	KELSEY GONZALEZ		FACILITY TYPE:	740
ADDRESS:	22424 CHARLENE WAY		TELEPHONE:	(510) 889-1300
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	49	CENSUS: 29	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Teresa Truong, Administrator		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Facility failed to allow indoor compassion care visits

INVESTIGATION FINDINGS:

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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 allow indoor compassion care visits. During the course of the investigation, the Department conducted interviews with facility staff, and reviewed records for R1. R1 was under the care of a hospice agency. R1’s daughter was not allowed by the facility staff to visit. R1’s daughter states that she has been observing safety precautions so she should have been allowed to visit R1, hold her hand and talk to her at the facility.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 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)

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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

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However, facility still refused to let her visit. Administrator confirmed with the Department that at that time the facility has not allowed any visitation since March 2020. Administrator stated on 8/21/2021 that she is aware of guidelines outlined in PIN 20-38 ASC issued in October 2020 in regard to end of life visitation. However, despite knowing the guidelines, Administrator states that she did not and will not allow end of life visitation. Therefore, the above allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 Sec 87468.1(11) Personal Rights of Residents in All Facilities, is being cited on the attached LIC 9099D.

Failure to correct deficiency by POC date may result in civil penalties.

Exit interview conducted with Administrator; Appeal Rights was provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 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)

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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/02/2022 Section Cited CCR 87468.1(11)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities: To have their visitors, .... permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC date, Administrator will review the current visitation guidelines provided in PIN 22-28-ASC and condicte a staff meeting with to review the guidlines with staff.
	8 9 10 11 12 13 14	Based on interviews conducted, Administrator confirmed that she did not allow visitors to the facility despite guidelines on end of life visitation issued by CCL in October 2020 which poses a potential risk to the health and safety of the resident under care.	8 9 10 11 12 13 14	Administrator will show proof of staff meeting and will develop and implement a plan for allowing end of life visitation to the facility and submit plan to CCL by POC date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC9099 (FAS) - (06/04)

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