075601431-10-13-2020-15-AS-KHOS-BUKLFY-20201020084353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 10/13/2020
Date Signed: 10/13/2020 02:45:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/14/2019 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191014150649

FACILITY NAME:	WALNUT CREEK WILLOWS		FACILITY NUMBER:	075601431
ADMINISTRATOR:	DOLLY RIZVI		FACILITY TYPE:	740
ADDRESS:	2015 MT. DIABLO BLVD.		TELEPHONE:	(925) 256-8708
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	72	CENSUS: 40	DATE:	10/13/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Marilou Ladaban, Facility Supervisor		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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-Resident sustained an injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Facility Supervisor Marilou Ladaban to deliver findings on the above allegation. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference. It was alleged that R1 fell and sustained an injury due to lack of care and supervision. During the investigation, LPA conducted interviews, made observations, and obtained documentation related to the allegation. An incident report indicated R1 fell in front of the bathroom. Additional records reviewed indicated staff immediately initiated medical intervention, including assessing R1 for injuries, calling 911 and implementing an updated care plan after R1's hospital release.

Based on information gathered during the investigation, there was not a substantial amount of evidence to support the allegation and no independent evidence or witnesses could be obtained to support R1 sustained fall due to lack of supervision. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2020

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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