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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 05/01/2024
Date Signed: 05/01/2024 12:47:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
04/29/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240429125748
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
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rizza Madlangbayan, Administrative AssistantTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
1. Staff did not ensure a written care plan was completed for resident in care
INVESTIGATION FINDINGS:
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On 05/01/2024, at 10:15 am, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegation. LPA met with Rizza Madlangbayan and explained the reason for the visit. Licensee/Administrator, Elizabeth "Beth" Cortes, was phoned. Beth arrived approximately an hour later.

The following documents were obtained:
1. Resident Registry
2. Physician's Report (LIC 602A) for R1
3. Resident Appraisal (LIC603A)
4. Resident Plan of Care (Dated 04/16/24)
5. Appraisal Needs and Services Plan (LIC625)
6. Physician's Orders
7. Appointment of Representative (MC306)
8. SNF Transition Checklist

LIC9099-C Continued
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20240429125748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/01/2024
NARRATIVE
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LIC809-C Continued...

Allegation: Staff did not ensure a written care plan was completed for resident in care
Unsubstantiated.

On 05/01/24 LPA spoke to RP who stated that R1 did not have a care plan on file. RP states that R1 was admitted on 04/16/24. LPA interviewed S1 who stated that the Walnut Creek Willows Resident Plan of Care and Resident Appraisal was completed on 04/16/24 for R1. LPA reviewed the documents for R1 which included: Physician's Report, Resident Appraisal, Walnut Creek Willows Resident Plan of Care and Appraisal Needs and Services dated 04/16/24. Based on information reviewed and interview the allegation is unsubstantiated.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2