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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601180
Report Date: 10/21/2020
Date Signed: 10/21/2020 04:06:36 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:WELCOME HOME SENIOR RESIDENCE (WALNUT CREEK)FACILITY NUMBER:
075601180
ADMINISTRATOR:CHOU, STEVEFACILITY TYPE:
740
ADDRESS:2421 WASDEN COURTTELEPHONE:
(925) 944-0204
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 2DATE:
10/21/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Steve Chou, Licensee/Administrator
Gladys Enriquez, Caregiver
Brian Baguilat, Caregiver		TIME COMPLETED:
03:30 PM
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On 10/21/20 at 3:00 PM, Licensing Program Analyst (LPA) D Panlilio conducted a Face-time Health and Safety check via tele-visit as a result of the department receiving a complaint during the COVID 19 shelter in place order. LPA explained the reason for the tele-visit with S1 and S2 was to conduct a health & safety check on the residents and staff. LPA also completed a Face-time tele-visit with Licensee/Administrator on the same day. He was not physically available to sign this report due to COVID-19 shelter in place order.

During the health and safety check, LPA observed a total of 2 staff members and 2 residents at the facility. LPA toured facility with S1 & S2, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
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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