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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600012
Report Date: 08/19/2022
Date Signed: 08/19/2022 04:50:50 PM

Document Has Been Signed on 08/19/2022 04:50 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:
08/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Levi Villareal, LicenseeTIME COMPLETED:
05:10 PM
NARRATIVE
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On 8/19/2022 at 1:00PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Licensee, Levi Villareal and explain the purpose of the visit.

LPA attempted to visit the facility on 8/3/2022 for an annual inspection and on 8/18/2022 for a POC visit. On both occasions LPA was not able to enter the facility. LPA was not able to open the gate to get to the front door of the facility. LPA observed a doorbell attached to the gate but it was not operable. LPA called the facility several times while standing outside of the gate as well as left a message. Licensee did not open the gate or return LPA's call.

Licensee will submit an addendum to the plan of operation for dementia care.

Civil penalty of $500.00 will be assessed on today's date.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). A $500.00 civil penalty is assessed for deficiency # 87755(a). Failure to submit proof of correction by due date may result in additional civil penalties.

Exit interview conducted. A copy of this report, LIC9098, LIC421M, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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Document Has Been Signed on 08/19/2022 04:50 PM - It Cannot Be Edited


Created By: Laura Hall On 08/19/2022 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WILLOW GLEN RESIDENCE
FACILITY NUMBER: 075600012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2022
Section Cited
CCR
87755(a)

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87755 Inspection Authority of the Licensing Agency
(a) Any duly authorized officer, employee... of the licensing agency may... enter and inspect the entire premise... at any time, with or without advance notice.
This requirement was not as evidence by:
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Licensee agreed to attach new doorbell, to review and abide by regulation 87755, and to submit photo of new doorbell and copy of self-certification to CCLD by POC date.
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Based on LPA's observation the Licensee did not comply with the section cited above in facility being accessible for Department, which poses a potential health and safety risk for persons in care.
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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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022


LIC809 (FAS) - (06/04)
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