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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:52:15 PM


Document Has Been Signed on 05/08/2024 04:52 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WALNUT CREEK WILLOWSFACILITY NUMBER:
075601431
ADMINISTRATOR:CORTES, ELIZABETHFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:72CENSUS: 44DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:ELIZABETH CORTES, ADMINISTRATORTIME COMPLETED:
05:30 PM
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On 5/8/2024 at 2:10PM, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to conduct a case management visit regarding an incident report. LPA met with Elizabeth Cortes, Administrator and explained the reason for the visit.

The Department received an incident report dated 5/2/2024. It was alleged that S1 was grabbing R1 in a rough manner while pulling and tugging aggressively, S2 was walking passed and witnessed this. S3 witnessed R1 eating R1's food when it's brought to the room. Witnesses were unavailable to interview, a written statement was provided to LPA. LPA interviewed POA via phone call. POA stated that S1 has been a caregiver with POA family for 14 years and POA wants to keep S1 on as a personal care giver, POA stated that S1 will be going through care giver training with Suncrest Hospice. POA also stated that when S1 is in need of help with R1, S1 will ask staff at the facility for help. POA also stated that S1 was interviewed by Contra Costa Police department and it was determined that there were signs of abuse on R1.

Exit interview conduct and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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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