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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600012
Report Date: 08/03/2022
Date Signed: 08/11/2022 02:44:18 PM


Document Has Been Signed on 08/11/2022 02:44 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 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:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Levi Villareal, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 8/3/2022 at 09:25AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a 1-year annual infection control inspection.

Upon arrival LPA rang doorbell that is located outside of locked entry gate. LPA called facility 3xs and the voicemail box was full. LPA was able to see a recycling bin outside of facility. No cars were present. LPA was able to peak through fence and saw the blinds were open. LPA will attempt visit at a later date.

On 8/11/2022 at 11:25AM, 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 and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 116.2 degrees Fahrenheit. Fire extinguisher last serviced on 7/19/2019. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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
VISIT DATE: 08/03/2022
NARRATIVE
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Continued from LIC809.

During record review, LPA observed facility has a copy of the mitigation plan on file. LPA observed food and paper supplies are sufficient.

The following deficiencies were observed:

-At 10:42AM, LPA observed Ajax, windex, and raid in unlocked cabinet under kitchen sink.
-At 11:55AM, LPA observed R1 on hospice care. Facility does not have hospice waiver.
-At 12:05PM, LPA observed while reviewing R1's file that the file is missing the following documents: personal rights, personal safeguard, Identification and emergency information, and a care plan for hospice services. The following documents are outdated appraisal needs and services plan, and physician's report.
-At 12:15PM, LPA observed that Administrator certificate expired on 2/19/2022.
-At 12:20PM, LPA observed that Administrator was not following requirement duties for Administrator.

LPA request the following documents to be submitted to CCLD by 8/18/2022.

LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report provided and appeal rights provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2022 02:44 PM - It Cannot Be Edited

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: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having Ajax, Raid, and Windex accessible in unlocked cabinet under kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Administrator agreed to make disinfectants inaccessible to residents in care and submit photo to CCLD by POC date. Administrator locked disinfectants in hallway closet during visit. Deficiency cleared.
Type A
Section Cited
CCR
87632(a)

87632 Hospice Care Waiver



(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be 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 having a hospice waiver approved by the department on file and there is a hospice resident residing in facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Administrator agreed to submit a request for a hospice waiver to CCLD by POC date

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: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 08/11/2022 02:44 PM - It Cannot Be Edited

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: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties



(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

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 having a certified Administrator employed at facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Licensee agreed to submit a plan to hire an Administrator or to recertify as the Administrator for the facility and submit a copy of the plan to CCLD by POC date.

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: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 08/11/2022 02:44 PM - It Cannot Be Edited

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: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)
87405 Administrator Qualifications.
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in following the administrator duties for facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Licensee agreed to review regulation 87405 and submit a self-certification that the regulation has been reviewed and facility will abide by the regulation. Self-certification shall be submitted to CCLD by POC date.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 having R1's file is complete and up-to-date which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Licensee agreed to complete R1's file and submit a self-certification that the file has been completed by POC date.

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: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 9 of 9