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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 04:39:44 PM


Document Has Been Signed on 09/06/2024 04:39 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 - Health ChecksUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Lynette Sandoval, Admissions DirectorTIME COMPLETED:
03:00 PM
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On 09/06/2024 at 11:55 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management Health and Safety check as a result of the Department learning that the Licensee filed bankruptcy. LPA met with Admissions Director, Lynette Sandoval and explained the purpose of the visit. Lynette phoned Licensee/Administrator, Elizabeth Cortes to inform.

During the health and safety check, LPA observed a total of one (1) Staff in the front common areas preparing for resident social activity with Bingo. LPA observed residents sitting in their wheelchairs or laying in their beds in their apartment bedrooms. LPA observed the residents in the Memory Care area sitting in the common area watching television and some residents were in their bedrooms watching television or laying in their beds. LPA observed that the kitchen was clean and the food supply was sufficient.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report 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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