075601431-7-6-2023-15-AS-LAWN-CTGTTT-20230706150117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:01:21 PM

Document Has Been Signed on 07/06/2023 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	DATE:	07/06/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	11:07 AM
MET WITH:	Marisol Goco, Acting Administrator		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/6/2023 at 11:07 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Proof of Correction visit. LPA was not greeted at the front lobby entrance but proceeded to the Administrator's office. Acting Administrator, Marisol Goco (#6018647740 Expires 08/02/24), was sitting in the office and that is who the LPA met for the visit. During Proof of Correction visit, LPA toured facility including but not limited to bedrooms, bathrooms, common areas, and backyard areas. For deficiency 87307(d)(6), LPA observed that outside back and side yards were cleared. Deficiency cleared. For deficiency 1569.618(c)(3), LPA reviewed fax confirmation that was sent to CCL on 7/5/23 requesting an extension. Administrator and LPA agreed until 7/21/23 for staff to complete an online course/training for First Aid/CPR Certification. Administrator will send a copy of all staff's names that attends the training and have receipt of their certifications. For deficiency 1569.618(a) and 1569.618(b), LPA reviewed fax confirmation that was sent to CCL on 7/5/23 that included LIC 308 "Designation of Facility Responsibility". Deficiency cleared. For deficiency 87468(c)(2)(A), LPA observed complaint poster, personal rights and non-discrimination notice posted in all entry including Memory Care and Independent Care units. Deficiency cleared. LIC 809C Continues...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

For deficiency 87618(b)(3)(A), LPA reviewed letters dated June 26, 2023 were addressed to Contra Costa Fire Protection District. The 3 residents on oxygen have "Oxygen in Use" signs posted outside their bedroom doors.

A total of $100 Civil Penalty is being assessed today for the period of one day for failure to clear deficiency for section 87705(c)(6). LPA advised the administrator that Civil Penalties will continue to be assessed daily until corrected. Administrator says that they will have Appraisal Needs and Services Plans updated for R1, R2, R3, R4 and R5 and signed by responsible party no later than 7/21/23.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2