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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 08/09/2024
Date Signed: 08/09/2024 04:14:35 PM


Document Has Been Signed on 08/09/2024 04:14 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: 50DATE:
08/09/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lynette Sandoval, AdmissionsTIME COMPLETED:
01:30 PM
NARRATIVE
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On 08/09/2024 at 9:30 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Plan of Correction (POC) visit. LPA met with, Manager, Marilou Ladaban. Licensee/Administrator, Elizabeth Cortes, was available for a brief moment but had to leave.

The facility submitted an appeal that was received by Regional Office on 05/03/2024. The appeal was in response to citation deficiencies 80087(a), 87608(a)(3) and 87211(b) that in which 80087(a) and 87211(b) were assessed civil penalties on 04/11/2024 and 05/01/2024. On 07/31/2024 the appeal was denied by Regional Office.

Facility has the following deficiencies cleared:

Deficiency CCR 87608(a)(3) cleared on 05/01/2024.
Deficiency CCR 87211(b) cleared on 04/19/2024.

Facility has the following deficiencies that was not cleared:

Deficiency CCR 80087(a) not cleared.



Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report, appeal rights and LIC421FC provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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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Document Has Been Signed on 08/09/2024 04:14 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: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds
(a) The facility shall be...in good repair at all times...

This requirement is not met as evidenced by:
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Licensee agreed to submit a detail plan of when they will have the flooring completely repaired and submit photos of repaired floors to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above by having disrepair flooring in residents rooms and hallways which poses a potential health and safety risk to persons in care.
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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: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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