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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601180
Report Date: 11/05/2020
Date Signed: 11/05/2020 06:34:54 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201016155221
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:
11/05/2020
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Steve ChouTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility failed to report the bankruptcy to CCLD.
INVESTIGATION FINDINGS:
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On 11/05/2020 at 04:45 PM, Licensing Program Analyst (LPA), L. Hall conducted an unannounced continuing complaint visit, meeting with S1. Due to the State’s current shelter-in-place order, the visit was conducted via telephone.
In the course of investigation, it was found that a bankruptcy filing for the facility was made on 9/24/20 and on 10/21/20, S1 verbally confirmed with CCLD that the agency had not been informed.

The Department has conducted an investigation into the above allegation and based upon observations, records review, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20201016155221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
VISIT DATE: 11/05/2020
NARRATIVE
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Continued from LIC9099.

A Civil Penalty of $2,000.00 is being assessed on this date for violation of Health & Safety Code 1569.686, failure to notify CCLD in writing for specified events.
Deficiency is cited per Title 22 California Code of Regulations and listed on the LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in additional civil penalties.

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

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20201016155221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/06/2020
Section Cited
HSC
1569.686(a)(3)
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Licensee notification of specified events…(a) A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents...in writing...{when the licensee files for bankruptcy}. This requirement was not met as evidenced by:
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By POC date, Licensee will issue written notifications to Residents, Ombudsman, and CCLD of bankruptcy, and will submit copies to CCLD. A $2,000.00 civil penalty is assessed on this date.
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LPA.confirmed with S1 that this facility filed for bankruptcy and that CCLD was not notified within 2 business days, which poses an immediate threat to the health and safety of residents 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3