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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600012
Report Date: 08/17/2021
Date Signed: 08/17/2021 04:31:03 PM

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 GLEN RESIDENCEFACILITY NUMBER:
075600012
ADMINISTRATOR:VILLAREAL, LEVIFACILITY TYPE:
740
ADDRESS:2040 MENDOCINO DRIVETELEPHONE:
(925) 458-5057
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY:5CENSUS: 1DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Levi Villareal, AdministratorTIME COMPLETED:
04:35 PM
NARRATIVE
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On 08/17/2021 at 02:45PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Levi Villareal, Administrator and explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA observed screening station at entrance with hand sanitizer, thermometer, face mask. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, and kitchen. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters were posted.

During record review, LPA observed visitors log. LPA observed PPE, food, and paper supplies are sufficient.

-At 2:50PM, LPA observed facility did not have a mitigation plan on file.

The following deficiency was observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 GLEN RESIDENCE
FACILITY NUMBER: 075600012
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)
87211 Reporting Requirements

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not have a mitigation plan on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2021
Plan of Correction
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Administrator agreed to submit a copy of the mitigation plan (LIC808) to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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