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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601579
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:44:36 PM


Document Has Been Signed on 03/27/2023 01:44 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:
03/27/2023
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Donald HayTIME COMPLETED:
02:00 PM
NARRATIVE
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Upon arrival at the facility at 10:00 AM to conduct an unannounced complaint inspection, Licensing Program Analyst (LPA) J. Sampair observed that no staff were wearing masks.

LPA met with Licensee Donald Hay and reviewed SECTION IV of PIN 23-02-ASC dated February 9, 2023 and titled RESPIRATORS AND MASKING REQUIREMENTS IN ASC FACILITIES, which states: "Masks are required for individuals (other than residents) in indoor settings at ASC facilities, regardless of vaccination status, to continue to control the spread of COVID-19 pursuant to the State Public Health Officer Order (Beyond the Blueprint PHO) of October 13, 2022."

Licensee acknowledged that he and his staff had not been following that COVID-19 guidance and promised to follow it moving forward.

Facility cited for that deficiency as per Title 22 of the California Code of Regulations listed on the LIC9099-D.

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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 03/27/2023 01:44 PM - It Cannot Be Edited

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 SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited

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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES (a) Residents ... have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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Cleared during inspection when all staff put on masks and Licensee acknowledged that he did not know of that requirement by the Department and the California Department of Public Health.
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Based on observation by LPA J Sampair on 03/27/2023 at 10:00 AM of no ataff wearing a mask, Licensee failed to protect the personal rights of residents, which poses a potential health and safety risk to residents 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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