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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601579
Report Date: 04/05/2023
Date Signed: 04/05/2023 10:28:35 AM


Document Has Been Signed on 04/05/2023 10:28 AM - 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:
04/05/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Caregiver Pamie Palpallatoc TIME COMPLETED:
10:45 AM
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On 04/05/2023 at 8:45 AM, Licensing Program Analyst (LPA) J. Sampair conducted a Plan of Correction (POC) inspection. Upon entry into facility, LPA explained the purpose of the visit with Caregiver Pamie Palpallatoc.

This visit was prompted by the licensee's failure to provide documentation to the LPA that the citation from 03/27/2023 had been corrected. When LPA entered facility, he observed that the licensee had not replaced the key-operated locks facing inside with locks that could be operated without a key in either of the 2 doors as per the POC.

Failure to correct that deficiency has resulted in a civil penalty (see LIC 421FC).

Exit interview conducted and civil penalty with appeal rights documentation provided to Licensee via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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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