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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 06/05/2024
Date Signed: 06/05/2024 09:27:24 PM


Document Has Been Signed on 06/05/2024 09:27 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:CORTES, ELIZABETHFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:72CENSUS: 49DATE:
06/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Elizabeth Cortes, Licensse/AdministratorTIME COMPLETED:
09:40 PM
NARRATIVE
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On 06/05/2024 at 1:25 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Elizabeth Cortes and Marketer, Lynette Sandoval explained the purpose of the visit. The facility’s fire clearance was approved for capacity 72 in which all non-ambulatory, of which may be bedridden and a hospice waiver of fifteen (15) residents. Administrator Certificate # #6017472740 expires 06/04/2024.

LPA toured the facility with Lynette including but not limited to 2 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 63 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 128.5, 120.0, 122.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

LPA reviewed 10 residents records. LPA reviewed 10 staff records and 9 of 12 have current first aid training and associated to the facility.

LIC809-Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024
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 14


Document Has Been Signed on 06/05/2024 09:27 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by not having health screening and negative TB results which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Administrator will submit health screening for S3, S5, S7-S12 and a Negative TB for S2, S4, S5, S7-S12.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 14


Document Has Been Signed on 06/05/2024 09:27 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by not reporting to the local fire dept oxygen in use for R1 and R2 which poses a potential health and safety risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Administrator agree to send a letter to local fire dept and submit a copy of letter to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 14


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: 06/05/2024
NARRATIVE
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LIC809-C Continued...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/12/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
Page: 13 of 14
Document Has Been Signed on 06/05/2024 09:27 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by not having a Emergency Disaster Plan which poses a potential health and safety risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Administrator will submit a copy of Emergency Disaster Plan to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024
LIC809 (FAS) - (06/04)
Page: 14 of 14