075601431-3-29-2024-15-AS-KHOS-D45R8D-20240408124745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 03/29/2024
Date Signed: 03/29/2024 05:47:30 PM

Substantiated

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
03/27/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240327083732

FACILITY NAME:	WALNUT CREEK WILLOWS		FACILITY NUMBER:	075601431
ADMINISTRATOR:	GOCO, MARISOL		FACILITY TYPE:	740
ADDRESS:	2015 MT. DIABLO BLVD.		TELEPHONE:	(925) 256-8708
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	72	CENSUS: 44	DATE:	03/29/2024
		UNANNOUNCED	TIME BEGAN:	01:14 PM
MET WITH:	Rizza Madlangbayan, Administrative Assistant		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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1. Facility floor is in disrepair
2. Facility staff did not report incident as required

INVESTIGATION FINDINGS:

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On 03/29/2024, at 1:14PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegations. LPA met with Rizza Madlangbayan and explained the reason for the visit. Licensee/Administrator, Elizabeth "Beth" Cortes, was phoned. Beth arrived shortly after but left at 1:56PM.

The following documents were obtained:
1. Unuusal Incident Report (LIC 624) for incident occured on 11/15/2023
2. Internal Incident Report dated 11/15/2023
3. Employee Grievance Form 11/16/2023

LIC9099-C Continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240327083732

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: 03/29/2024

NARRATIVE

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LIC9099-C

Allegation: Facility floor is in disrepair
Substantiated

On 03/29/2024 LPA observed cracks in the flooring, tape, nails and floor molding lifting up. LPA observed in multiple resident rooms that the tile flooring had tape attached to the floor tiles. LPA observed tape, nails and the floor molding lifting at the end of the hall towards kitchen.

Allegation: Facility staff did not report incident as required
Substantiated

On 03/29/2024 LPA reviewed Unusual Incident that was reported to CCLD on 11/16/2023. LPA interviewed S2, who gave a copy of the facility internal report. S2 confirmed that a SOC 341 was not completed and therefore the incident was not reported to the local ombudsmen.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted with Administrator. Appeal rights and copy of this report was provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240327083732

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/26/2024 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 Buildings and Grounds (a) The facility shall be...in good repair at all times... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agree to repair flooring in all areas where cracks, tape, nails and molding is lifting. Send an invoice of floor repairs and photos to CCLD by POC due date.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
Request Denied Type B 04/05/2024 Section Cited CCR 87211(b)	1 2 3 4 5 6 7	87211 Reporting Requirements (b) Any suspected physical abuse that results in serious bodily injury of an elder...shall be reported to the local ombudsman... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will go over reporting requirements and submit a self certification of understanding of reporting requirements.
	8 9 10 11 12 13 14	Based on record review and interview, the Administrator did not comply with the section above for not reporting to the local ombudsman and submitting SOC341 which posed a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	Administrator shall submit self-certification to CCLD by POC due date.

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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC9099 (FAS) - (06/04)

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