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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601579
Report Date: 11/30/2022
Date Signed: 11/30/2022 06:25:05 PM


Document Has Been Signed on 11/30/2022 06:25 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WALNUT CREEK SENIOR LIVINGFACILITY NUMBER:
075601579
ADMINISTRATOR:DONALD T. HAYFACILITY TYPE:
740
ADDRESS:80 CRAGMONT COURTTELEPHONE:
(925) 939-3635
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:8CENSUS: 7DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Donald HayTIME COMPLETED:
06:30 PM
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On 11/29/22, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry into facility, Upon entry, LPA explained the purpose of the visit with Licensee and Administrator Donald Hay.

Facility has a Covid-19 mitigation plan in place. The designated infection control leader is the Licensee. They have signage on the front door and in the facility requiring masking for all visitors and one central entry point designated for universal entry screening, visitor's log, and a no touch thermometer. Facility follows daily cleaning and sanitation of frequently touched surfaces with disinfectants.

Carbon monoxide and smoke detectors were fully functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. A written Emergency/Disaster plan was posted. Inside of the facility, it was 72 and the hot water was 120 degrees. Centrally stored medications were in locked cabinets.

Multiple deficiencies were observed and recorded by the LPA. However, there was inadequate time to complete the inspection so he will return unannounced on a future date to complete this inspection.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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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