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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 07/16/2021
Date Signed: 07/16/2021 01:22:50 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: 44DATE:
07/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Supervisor, Marilou LadabanTIME COMPLETED:
01:30 PM
NARRATIVE
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On 07/16/2021 at approximately 12:00pm Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a case management visit regarding a self-reported incident that occurred on 06/05/2021. LPA met with Supervisor Marilou Ladaban and explained the purpose of the visit.

During the visit LPA spoke and reviewed incident with Supervisor. Supervisor confirmed that Resident (R1) left the facility unsupervised and was found at the police department. Supervisor stated R1 may have left out of a side door that was propped open. LPA reviewed R1's physicians report that indicated that R1 was unable to leave facility unassisted.

Deficiency is being cited in violation of California Code of Regulation (see 809D) for repeat violation of deficiency section 87705(k)(8); the first citation was issued on 06/18/2021. An immediate civil penalty of $250.00 is assessed.


Exit interview conducted. Appeal Rights, LIC421 and copy of this report provided to Supervisor, Marilou Ladaban.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited

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Care of Persons with Dementia
The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors: Delayed egress devices shall not substitute for
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trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement was not met as evidenced by: Staff left delayed egress door wide open and Resident R1 left the facility unassisted which posed an immediate health & safety risk to 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021
LIC809 (FAS) - (06/04)
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