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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601256
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:40:08 PM


Document Has Been Signed on 02/15/2024 02:40 PM - It Cannot Be Edited

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: 34DATE:
02/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Elizabeth Carson, AdministratorTIME COMPLETED:
03:00 PM
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On 2/15/2024 at 1:50 PM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit to clarify/ gather information upon an incident report that LPA received on 2/06/24. LPA met with Administrator, Elizabeth Carson and explained the purpose of the visit.

LPA reviewed and obtained R1 after visit summary. LPA interviewed S1 regrading of the incident that led to R1 hospitalization. LPA reviewed R1 MAR. S1 stated R1 develop a cough on 2/2/24 doctor prescribed PRN. Staff was instructed to give med to R1 as prescribed by R1 doctor. On the day of 2/6/24 R1 daughter came to visit R1 was doing well. Around 7PM R1 was reported by a staff member that R1 wasn’t doing well. R1 daughter was notified and R1 sent out to the hospital. R1 had returned to the community with new med changes as well as diet change. R1 is now on home health. S1 spoke to R1 daughter and R1 daughter do not have any question regrading R1 condition.

No deficiencies issued during the visit and a copy of this report is provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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