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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 09/06/2024
Date Signed: 09/06/2024 04:36:11 PM


Document Has Been Signed on 09/06/2024 04:36 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:
09/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Lynette Sandoval, Admissions DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 09/06/2024, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management, meeting with Admissions Director, Lynette Sandoval. LPA explained the purpose of the visit, and the Licensee/Administrator, Elizabeth Cortes, was informed by phone of the visit.

On 09/05/2024, The Department learned that the Licensee had filed bankruptcy on 07/09/2024 and had not been notified. LPA interviewed Licensee by phone. Licensee confirmed with LPA that bankruptcy was filed and that the Department, the Ombudsman, and the Residents (or Responsible Parties) had not been notified. Per Statute, notices must be sent within 2 business days of bankruptcy filing.

A Civil Penalty of $2,000.00 has been assessed (calculated at $100.00 per day, up to $2,000.00)

Exit Interview conducted. A copy of this report and Appeal Rights provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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 09/06/2024 04:36 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: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
HSC
1569.686(a)(3)

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ยง1569.686 Licensee notificacified events..(a) A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within two business days, and shall notify all applicants for potential residence, and, if applicable, their legal representatives, prior to admission, of any of the following events, or knowledge of the event: (3) The licensee files for bankruptcy.

This requirement is not met as evidenced by:
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Licensee will submit copies of letters sent to Residents, Ombudsman, and a copy of the bankruptcy filing, LIC 500 to CCLD by POC date.

Civil Penalty of $2,000 is being assessed.
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Based on interview with the licensee did not comply with the section cited above in by not notifying the Department, Ombudsman and Residents of filed bankruptcy which poses a potential health, safety or personal rights 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: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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