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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601579
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:41:26 PM

Substantiated


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
03/21/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230321090125
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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Donald HayTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility has key operated deadbolt on the facility front door.
INVESTIGATION FINDINGS:
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On 03/27/2023 at 10:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to inspect facility concerning the allegation above. LPA explained purpose of the visit to staff S1 then and met with Licensee Donald Hay when he arrived at 11:30 AM.

During the visit, LPA interviewed staff and observed that the front door did have a key-operated deadbolt on the inside of the door. Based on the interview and observation, the preponderance of evidence standard has been met; therefore, the above allegation has been found to be SUBSTANTIATED.

Deficiency cited per Title 22 California Code of Regulations is 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.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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Control Number 15-AS-20230321090125
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 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
04/03/2023
Section Cited
CCR
87468.1(a)(6)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES (a) Residents ... have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any ... facility premises by day or night.

This requirement was not met as evidenced by:
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On or before the due date, Licensee shall replace the key-operated deadbolt facing inside of the front door AND the inside of the door between the kitchen and the garage with one that opens without a key facing inside of the facility.
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Based on observation by LPA J Sampair on 03/27/2023 at 10:10 AM of a key-operated deadbolt on the front door of the facility, Licensee failed to protect the personal rights of residents, which poses a potential health and safety risk to resident in care.
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On or before the due date, Licensee will send picture proof of the change to LPA J Sampair that the 2 locks have been replaced with ones that do not need a key to open from inside of the facility.
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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
LIC9099 (FAS) - (06/04)
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