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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 05/01/2024
Date Signed: 05/01/2024 12:49:55 PM


Document Has Been Signed on 05/01/2024 12:49 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 WILLOWSFACILITY NUMBER:
075601431
ADMINISTRATOR:GOCO, MARISOLFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:72CENSUS: 43DATE:
05/01/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Rizza Madlangbayan, Administrative AssistantTIME COMPLETED:
01:00 PM
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On 05/01/2024, at 11:15 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Rizza Madlangbayan, Administrative Assistant, and explained the purpose of the visit. Rizza contacted the Licensee, Elizabeth "Beth" Cortes, and inform that LPA was at the facility for a POC visit. The Licensee arrived approximately an hour later.

LPA toured the facility to check the flooring repairs. LPA observed cracks in the tile near the shower room in the main hallway. LPA observed silver tape on floor tiles still remained in several bedrooms (both North and South wing). LPA observed the molding was lifting in the TV common area in the North wing area.

Facility has the following deficiency that was not cleared:

  • 80087 (a) = $100.00 x 5 = $500.00

Civil Penalties in the total amount of $500.00 is assessed today for failure to meet POC date for deficiency. Facility is subject to ongoing daily civil penalties until deficiencies is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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