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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 09/24/2024
Date Signed: 09/24/2024 05:54:26 PM


Document Has Been Signed on 09/24/2024 05:54 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:
09/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Lynette Sandoval, Admissions DirectorTIME COMPLETED:
06:00 PM
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On 09/24/2024 at 12:55 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Admissions Director, Lynette Sandoval, and informed the reason for visit. Lynette phoned the Licensee/Administrator, Elizabeth Cortes to inform.

On 09/06/2024 LPA L. Alexander conducted a Case Management visit in which the following deficiency were not cleared by POC due date of 09/20/2024.

The following deficiency were not cleared by visit:
  • HSC 1569.686(a)(3) $100.00 x 4 days = $400.00

Civil penalty of $400.00 is assessed for the period of 09/21/2024 to 09/24/2024 for failure to correct deficiency. Facility is subject to ongoing daily civil penalties until deficiencies are corrected.

Exit interview conducted. A copy of this report, LIC 421FC 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: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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