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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 06/18/2021
Date Signed: 06/24/2021 01:21:16 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
06/15/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210615163312
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: 49DATE:
06/18/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marilou Ladaban, Facility SupervisorTIME COMPLETED:
04:29 PM
ALLEGATION(S):
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Staff failed to provide comfortable temperature for resident
Insufficient staffing to meet the residents' needs

INVESTIGATION FINDINGS:
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This report is an amendment to the original 9099 issued on 06/18/21. On 06/24/21 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation and met with facility supervisor to issue this amended report. LPA explained the purpose of the visit with facility supervisor.

During investigation, an in-person visit was conducted on 06/18/21 and it was observed that the inside temperature to be uncomfortably hot, causing sweating. The thermostats measured 79 and 80 degrees F. R1, R2 and V1 stated the inside temperature has been over 80 degrees F for 2 weeks. It was found that the central air conditioning system is non-operational and the floor fans & independent cooling units currently present were insufficient to maintain a comfortable temperature.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20210615163312
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: 06/18/2021
NARRATIVE
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It was also observed that 13 memory care residents had been moved from the secured memory care unit to an activities area near the front entrance and that they were observed to be unsupervised for 20 minutes.

Based on LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met. Therefore the above allegation(s) were found to be SUBSTANTIATED.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
06/15/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210615163312

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: 49DATE:
06/18/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marilou Ladaban, Facility SupervisorTIME COMPLETED:
04:29 PM
ALLEGATION(S):
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Staff failed to provide adequate food service
INVESTIGATION FINDINGS:
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On 06/18/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation and met with facility supervisor. LPA explained the purpose of the visit with facility supervisor.

LPA interviewed R1 and R2 who confirmed they eat 3 meals a day at the facility. LPA observed lists of south and north residents' dietary requirements posted on kitchen refrigerator doors next to the prep island. LPA interviewed S3 who stated that he prepares the daily food for breakfast, lunch and dinner according to the Good for Health Menu posted for each day. Each resident has the option to have alternate meals on request and are offered snacks and Ensure daily. LPA observed 13 memory care residents eating dinner (fresh salad, egg sanwich, split pea soup) in activity room. LPA observed one resident request pizza for dinner and staff arranged to have him delivered the pizza for dinner.

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

No deficiencies cited. Exit Interview conducted and a copy of this report provided to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210615163312
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2021
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Facility supervisor corrected deficiency during visit. Six new portable A/C units were purchased and installed in the south & north wings on 06/18/21 to ensure comfortable temperature is
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This requirement was not met as evidenced by broken A/C and hot temperature (79F & higher on other days) which posed an immediate health & safety risk to residents in care.
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maintained for all residents and staff inside the facility at all times.
Type B
07/16/2021
Section Cited
CCR
87705(c)(4)
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(c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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Faciity supervisor agreed to re-train staff on how to provide proper care and supervision to memory care residents. Proof of training done by a vendorized trainer with staff signatures must be submitted
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This requirement was not met as evidenced by no staff attending to 13 memory care residents in activity room for 20 minutes which posed a potential health & safety risk to residents in care
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to CCLD on or before POC due date.
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4