075601431-4-1-2021-15-AS-KHOS-C2VHUH-20210510063023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 04/01/2021
Date Signed: 04/01/2021 02:07:52 PM

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
10/02/2019 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191002125404

FACILITY NAME:	WALNUT CREEK WILLOWS		FACILITY NUMBER:	075601431
ADMINISTRATOR:	DOLLY RIZVI		FACILITY TYPE:	740
ADDRESS:	2015 MT. DIABLO BLVD.		TELEPHONE:	(925) 256-8708
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	72	CENSUS: 54	DATE:	04/01/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Marilou Ladaban, Facility Supervisor		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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9

Resident developed multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Facility Supervisor Marilou Ladaban to deliver findings on the above allegation. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference.

This complaint allegation was accepted by the Department's Investigations Branch (IB) as a full investigation. The Department reviewed records and conducted interviews. Based on R1's medical records and photos of R1's injuries resulting in a diagnosis of a urinary tract infection and cellulitis, there was not sufficient evidence to substantiate the neglect and lack of supervision allegation that resulted in multiple pressure injuries.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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