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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601579
Report Date: 01/23/2025
Date Signed: 01/28/2025 12:04:09 PM

Document Has Been Signed on 01/28/2025 12:04 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WALNUT CREEK SENIOR LIVINGFACILITY NUMBER:
075601579
ADMINISTRATOR/
DIRECTOR:		DONALD T. HAYFACILITY TYPE:
740
ADDRESS:80 CRAGMONT COURTTELEPHONE:
(925) 939-3635
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Licensee Donald HayTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 1/23/2025 at 8:00 AM, Licensing Program Analyst (LPA) James Sampair arrived for this unannounced Required 1 Year Inspection. Upon entry to the facility, the LPA informed Caregiver Danilo Danilesof the purpose of the visit. Licensee Donald Hay arrived at approximately 1:25 PM.

The LPA toured the facility inside and outside. The LPA inspected the kitchen, common areas, bedrooms, bathrooms, and the exterior of the facility. The facility was clean, appropriately furnished, and well lit. More than the 2 days of perishable and 7 days of nonperishable food supplies were available. No body of water is on the facility grounds.
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Medications are centrally stored. Bathrooms and showers were observed to be fully functioning and clean. Carbon monoxide and smoke detectors were operational. The fire extinguisher was last serviced on 02/26/2024. Inside temperature was 71 degrees Fahrenheit and the hot water temperature was 110 degrees Fahrenheit.

The LPA reviewed 5 resident files.

5 Type-B citations issued (refer to LIC 809-D).

The inspection is incomplete and the LPA will return unannounced at a different date and time to complete the full inspection.

Exit interview conducted and a copy of this report provided.
Harpreet HumpalTELEPHONE: (510) 529-9416
James SampairTELEPHONE: (510) 286-4201
DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 01/28/2025 12:04 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: WALNUT CREEK SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 0 of 5 resident files had complete records, including only the Admission Agreement and a Medical Assessment, and 1 contained only the Admission Agreement, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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On or before the due date, the Licensee shall complete the missing forms for each resident and shall send proof to the LPA.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 0 of 5 resident files included a pre-placement appraisal, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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On or before the due date, the Licensee shall complete the pre-placement appraisals for each resident and shall send proof to the LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet HumpalTELEPHONE: (510) 529-9416
James SampairTELEPHONE: (510) 286-4201

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2025 12:04 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: WALNUT CREEK SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 0 of the 5 resident files contain a reappraisal completed within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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On or before the due date, the Licensee shall complete the LIC 625 Appraisal & Needs and Services Plan form for each resident and shall send proof to the LPA.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 of the 5 resident files do not contain documentation of a routine medical visit within 12 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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On or before the due date, the Licensee shall document informing the responsible party and/or scheduling a routine medical visit and obtaining an updated LIC 602 for each of those 3 residents and shall send proof to the LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet HumpalTELEPHONE: (510) 529-9416
James SampairTELEPHONE: (510) 286-4201

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025

LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/28/2025 12:04 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: WALNUT CREEK SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87508(a)
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Register of Residents not up-to-date, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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On or before the due date, the Licensee shall send proof to LPA of the update to the Register of Residents.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Harpreet HumpalTELEPHONE: (510) 529-9416
James SampairTELEPHONE: (510) 286-4201

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025

LIC809 (FAS) - (06/04)
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