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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:21:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
07/08/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240708161505
FACILITY NAME:WALNUT CREEK WILLOWSFACILITY NUMBER:
075601431
ADMINISTRATOR:CORTES, ELIZABETHFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:72CENSUS: 49DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elizabeth Cortes, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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illegal eviction
INVESTIGATION FINDINGS:
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On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver findings of above allegation. LPA explained the purpose of the visit with Administrator.

During the course of investigation, LPA interviewed two (2) witnesses (W) W1, W2, two (2) staff (S) S1, S2 and resident (R) R1. LPA obtained and reviewed R1’s documents including Resident Appraisal, Physician’s Report, Admission Agreement, Advanced Health Care Directive, Letter of Agreement, Assisted Living Waiver Program document, Unusual Incident Report, Medication Technician Notes and Resident Registry.

LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 4
Control Number 15-AS-20240708161505
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WALNUT CREEK WILLOWS
FACILITY NUMBER: 075601431
VISIT DATE: 11/26/2024
NARRATIVE
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LIC9099-C (Page 2)

Allegation: illegal eviction
Finding: Substantiated

On 07/16/2024, the LPA interviewed S1 that stated R1 called 911 themselves and was transported to emergency room. S1 stated that R1 said that they were not coming back and that their ex-wife came to the facility to pick up all their personal belongings and confirmed that R1 was not coming back because they were going to another facility located in Antioch.

On 09/30/2024, the LPA interviewed W1 that stated R1 was transported to Kaiser Walnut Creek Emergency Room (ER) from Walnut Creek Willows (facility) on 07/01/2024. W1 stated that after R1 was treated in the ER, R1 was ready to be discharged and return to facility. W1 stated that they called Walnut Creek Willows several times but there was no answer. W1 stated that on 07/042024 they called the facility, and spoke to one of the Med Techs, (S2), that told them that R1 was discharged and that they were not taking him back. W1 stated that S2 told them that they could not make the decision. W1 further stated that when they did hear back from S3, they told them that they were not going to accept R1 back because they were notified that R1 was not going to return to the facility. W1 stated that S3 acknowledged that they did not give R1 a 30-day notice. W1 concluded statement that there were no bedside evaluations, no exploring alternative placement options, and no confirmation if facility had an opened bed available.

On 09/30/2024, the LPA interviewed W2 that stated R1 called 911 and was transported to Kaiser Walnut Creek Emergency on 07/01/2024. W2 stated that R1 was ready to be discharged on 07/03/2024 and that the facility refused to accept R1 back at the facility. W2 stated that they spoke with S1 that told them that R1 was the one that called 911 and that they were told that R1 was not coming back to the facility. W2 stated that at the time R1 was ready to be discharged from Kaiser Walnut Creek ER, that R1 did not have another confirmed placement at another facility. W2 stated that Kaiser team had to find another placement for R1.

LIC9099-C (Page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20240708161505
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WALNUT CREEK WILLOWS
FACILITY NUMBER: 075601431
VISIT DATE: 11/26/2024
NARRATIVE
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LIC9099-C (Page 2)

On 11/13/2024, the LPA interviewed R1 that stated they feared for their life because how they were being treated at the facility and that is why they called 911. R1 stated that they wanted to be checked out at the hospital and get some tests done. R1 stated that Kaiser was calling trying to get in touch with the administrator at Walnut Creek Willows but there was no response. R1 stated that they never told anyone at the facility that they were not coming back. R1 stated that they always paid their rent by the 5th of each month and paid by money order.

Based on LPA’s observations and interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20240708161505
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK WILLOWS
FACILITY NUMBER: 075601431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
87224(a)
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87224 Eviction Procedures

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)

This requirement is not met as evidenced by:
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The licensee will read regulation 87224 and submit self-certification that it has been read, understood and they will abide going forward to CCLD by POC due date.
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Based on interviews and record review the licensee did not comply with the section cited above in by serving R1 with an appropriate eviction notice after deciding not to accept R1 back to the facility once R1 was discharged from the hospital ER which posed a potential health and safety risk and personal rights to 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4