075601431-7-9-2021-15-AS-KHOS-CCRJKZ-20220322070755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 07/09/2021
Date Signed: 07/09/2021 12:16:39 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
04/22/2021 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20210422101430

FACILITY NAME:	WALNUT CREEK WILLOWS		FACILITY NUMBER:	075601431
ADMINISTRATOR:	DOLLY RIZVI		FACILITY TYPE:	740
ADDRESS:	2015 MT. DIABLO BLVD.		TELEPHONE:	(925) 256-8708
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	72	CENSUS: 42	DATE:	07/09/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marilou Ladaban, Facility Supervisor Elizabeth Cortes, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Facility does not have an Administrator.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 7/9/2021 at 9:00am, Licensing Program Analysts (LPAs), C. Fowler and G. Luk arrived unannounced to deliver complaint findings for the above allegation, LPAs met with Facility Supervisor, Marilou Ladaban and explained the reason for the visit. Administrator, Elizabeth Cortes arrived an hour later.

During the course of the investigation, 6 staff and 2 residents were interviewed. Interview with staff revealed that from January to March 2021, S5 was the administrator and S2 was the administrator from March. Facility was not able to provide Administrator schedule during March through May. However, staff (S9 & S10) stated that S2 works at least 20+ hours a week. LPAs verified that S2 has a current administrator certificate which expires on June 4, 2022.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED
Exit interview conducted with Administrator and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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