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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 08/21/2020
Date Signed: 08/21/2020 03:08:02 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: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: 49DATE:
08/21/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ruztin Cortes, LicenseeTIME COMPLETED:
03:00 PM
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On 8/21/2020 Assistant Program Administrator, Pam Gill, Regional Manager, Isaac Taggart, Licensing Program Manager, Yvonne Flores-Larios conducted a video conference with licensee, Ruztin Cortes. Also in attendance were Executive Director Nicole Howell and Debra Hanscher, Lead Regional Supervisor from Long Term Care Ombudsman.

The purpose of this video conference was to follow up to concerns regarding infection control and staffing.

No deficiencies were cited on this visit. Exit interview conducted and a copy of this report sent to licensee via email.
SUPERVISOR'S NAME: Pam GillTELEPHONE: (510) 286-4352
LICENSING EVALUATOR NAME: Yvonne Flores-LariosTELEPHONE: 510-286-0517
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
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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