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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 04/01/2021
Date Signed: 04/01/2021 02:09:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WALNUT CREEK WILLOWSFACILITY NUMBER:
075601431
ADMINISTRATOR:DOLLY RIZVIFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:72CENSUS: 54DATE:
04/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marilou Ladaban, Facility SupervisorTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Marilou Ladaban, Facility Supervisor. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference.

While investigating complaint control # 15-AS-20191002125404, the Department's Investigation's Branch (IB) Investigator experienced continued difficulty in obtaining information and compliance from facility Administrator Dolly Rizvi. Significant efforts had to be made to obtain records and conduct interviews which resulted in substantial delays in completing the investigation.

Deficiencies are cited per California Code of Regulations, Title 22, and begins on the next page. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted and a copy of this report and Appeal Rights provided via email.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2021
Section Cited

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Inspection Authority of the Licensing Agency. (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).
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This requirement is not met as evidenced by Administrator's failure to cooperate during an investigation by the Department.

Administrator Dolly Rizvi continually delayed requests made by IB Investigator to inspect records and conduct interviews.
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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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2021
LIC809 (FAS) - (06/04)
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