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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 08/16/2020
Date Signed: 08/16/2020 10:58:22 AM

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:WALNUT CREEK WILLOWSFACILITY NUMBER:
075601431
ADMINISTRATOR:DOLLY RIZVIFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:72CENSUS: 50DATE:
08/16/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marilou LadabanTIME COMPLETED:
11:15 AM
NARRATIVE
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On 8/16/20 at 9:30 am Associate Governmental Program Associate Jeremy Fong conducted an announced Health and Safety check of the facility, meeting with senior staff person Marilou Ladaban. A tour of the exterior and interior of the facility was performed.

Facility is adequately clean and organized. All power and water was operational. There was no garbage build-up in any indoor or outdoor areas. There was adequate 2 days supply of perishable and 7 days of non-perishable foods in stock. Food storage was clean and organized; all foods were properly contained and/or wrapped. A spot check of canned/packaged foods was made, with no expiration dates noted. Foods in stock represent all major food groups; there was no freezer burn observed on the frozen meats. All doors are alarmed in both assisted living and memory care; a door was checked in memory care and the alarm was activated. A random spot check was made of the medications with no issues. AGPA JF observed that the residents were adequately groomed and attired, and they interacted appropriately. There were no visible marks or bruising observed on the residents. Fire extinguishers were all checked by the FD within the past year.

Deficiency: AGPA JF observed that there was a can of de-greaser in an unlocked cabinet in the Memory Care unit. The item was immediately removed and secured.

Deficiency cited per California Code of Regulations, Title 22. Failure to correct the deficiency by the due date may result in civil penalties. This report was reviewed with Ms. Ladaban, and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2020
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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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: WALNUT CREEK WILLOWS
FACILITY NUMBER: 075601431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2020
Section Cited

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The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement was not met as evidenced by:
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AGPA Jeremy Fong observed an unsecured can of de-greaser in an unlocked cabinet in the memory care unit, which is 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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2020
LIC809 (FAS) - (06/04)
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