075601431-7-8-2021-15-AS-DPAO-C4QVFE-20210708162350

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:24:05 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 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: 49	DATE:	07/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Marilou Ladaban, Administrator		TIME COMPLETED:	04:23 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/08/21 at 3:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 7 staff wearing face masks during visit. LPA observed 10 residents playing bingo in the main visitation room with two staff wearing face masks. LPA observed screening station located at the front desk with staff entering information on the visitor's log and using the no touch temperature probe for daily symptom screening (+/-) temperature & symptom check. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. Facility has a completed mitigation plan in place dated 06/01/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed facility walls, bedrooms, bathrooms and common areas were freshly painted. Administrator stated COVID-19 signages will be posted again in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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
	VISIT DATE: 07/08/2021

NARRATIVE

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Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Facility has living areas with furniture spaced six feet apart for social distancing among residents. All staff and residents have been fully vaccinated since May 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Infection control designated leader is the administrator. Emergency food supplies were observed stored in locked storage room. Medications were observed locked in medication carts outside the medication room. Infection control leader is the administrator.

Facility room temperature was observed at 70 degrees F per thermostat reading. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged. Smoke and Carbon monoxide detectors were operational. LPA observed communal dining area with tables six feet apart.

Updated copies of the following documents will be emailed to LPA by administrator on 07/12/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC809 (FAS) - (06/04)

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