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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:06:14 PM

Document Has Been Signed on 03/06/2025 04:06 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/
DIRECTOR:		CORTES, ELIZABETHFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY: 72CENSUS: 53DATE:
03/06/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Elizabeth Cortes, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 03/06/2025 at 2:30 pm Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with Administrator/Licensee, Elizabeth Cortes and explained the purpose of the visit.

While LPA was at the facility for a complaint investigation (15-AS-20250303150627) and taking a self guided tour of the kitchen deficiencies were observed.



THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 1:53pm, LPA observed three (3) cases of Clorox Bleach and one (1) 210 oz bottle of Fabuloso Multi-Purpose Cleaner, Lavender sitting on the floor in the food pantry/storage area which was unlocked

At 1:54pm, LPA observed one (1) case of Clorox Bleach and two (2) 210 oz bottles
of Fabuloso Multi-Purpose Cleaner, Lavender sitting on the floor in the food pantry/storage area between freezer and refrigerator.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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Document Has Been Signed on 03/06/2025 04:06 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 03/06/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK WILLOWS
FACILITY NUMBER: 075601431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2025
Section Cited
CCR
87555(b)(25)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
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Administrator agreed to remove the cleaning disinfectant products and send a photo. In addition, read the regulation and self-certify understanding the regulation moving forward. POC documents will be sent to CCLD by POC due date.
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Based on observation, the licensee did not comply with the section cited above in by not storing cases of Clorox Bleach and bottles of Fabuloso Multi-Purpose Cleaner in a area separate from food supplies which poses a potential health and safety risk to persons in care.
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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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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