075601431-10-29-2024-15-AS-KHOS-DBDQBG-20241126110131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 10/29/2024
Date Signed: 10/29/2024 05:34:06 PM

Unsubstantiated

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
10/21/2024 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20241021143448

FACILITY NAME:	WALNUT CREEK WILLOWS		FACILITY NUMBER:	075601431
ADMINISTRATOR:	CORTES, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	2015 MT. DIABLO BLVD.		TELEPHONE:	(925) 256-8708
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	72	CENSUS: 51	DATE:	10/29/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lynette Sandobal, Admissions and Marketing Director		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Resident was not accorded safe, healthful comfortable accommodations

INVESTIGATION FINDINGS:

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On 10/29/2024 at 3:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct an initial 10-day visit and deliver complaint findings for the allegation above. Lynette Sandobal, Admissions and Marketing Director, and explained the reason for the visit. Administrator, Ellizabeth Cortes, came in at 3:25pm.

LPA interviewed staff, resident, obtained resident roster, staff roster, a list of R1's medications, emergency contact and identification, and a copy of motorized wheelchair demo visit.

Based on witness' interview R1 is uncomfortable and in pain sitting in the wheelchair. S2 stated that R1 is on the fourth loaner wheelchair and facility has been trying to assist R1. S2 also stated R1 is waiting on insurance approval for a motorized chair. and if the facility orders a customized chair the motorized chair will be canceled.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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-20241021143448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK WILLOWS	FACILITY NUMBER: 075601431
	VISIT DATE: 10/29/2024

NARRATIVE

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Continued from LIC9099.

During interview R1 stated the chair is uncomfortable but wants to wait for the motorized chair. During visit caregiver placed towel between R1 and arm rest of wheelchair to relieve some pressure. S1 stated power of attorney is coordinating with doctors for motorized chair and it has been approximately four (4) months.

Based upon the information obtained and the interviews conducted during investigation the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC9099 (FAS) - (06/04)

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