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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 04/25/2022
Date Signed: 04/25/2022 11:49:53 AM


Document Has Been Signed on 04/25/2022 11:49 AM - It Cannot Be Edited

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: 43DATE:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Cecily Palma, AdministratorTIME COMPLETED:
12:00 PM
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On 04/25/2022 at approximately 9:05am Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a case management visit regarding a self-reported incident that occurred on 04/05/2022. LPA met with Administrator Cecily Palma and explained the purpose of the visit.

During the visit, LPA obtained relevant documents and interviewed Administrator.
2/3/22, Resident (R1) was admitted to facility from a Skill Nursing Facility.
2/9/22, R1 started receiving home health service due to physical therapy through Neogen Home Care.
2/18/22. Home care services was discontinued of visiting resident, but service was still active.
3/21/22, Redness on R1's buttocks area was noticed, Administrator notified Neogen Home Care, Neogen sent nurse (W1) to visit R1 on the same day. R1's POA and physician were notified.
3/23/22, Nurse (W1) revisited resident and determined the wound was stage 2. Home health nurse provided wound care services to R1 two times per week.
4/4/22, Nurse (W1) noticed the wound became stage 3, R1 was sent to hospital for treatment. Administrator stated that R1's POA and physician were notified.
4/7/22, R1 was admitted to skill nursing facility after discharging from hospital. R1's wound has not been getting better during the time from hospital to skill nursing facility.
4/19/22, Skill Nursing facility submitted request to initiate hospice service for R1 due to Degenerative Disease of Nervous System. Suncrest delivered an APP air mattress to facility for R1.
4/20/22, R1's hospice service was initiated through Suncrest Hospice. R1 was requested to return to facility per POA. Administrator stated that hospice nurse arrived at facility before resident returned.
4/20/22, Administrator updated Needs and Service Plan for resident.

No deficiency cited during visit. Exit interview conducted with Administrator and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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