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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200580
Report Date: 12/10/2020
Date Signed: 12/10/2020 05:15:31 PM

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:HEATHERWOOD MEMORY CAREFACILITY NUMBER:
079200580
ADMINISTRATOR:FERNANDEZ, RYANFACILITY TYPE:
740
ADDRESS:1315 MT PISGAH ROADTELEPHONE:
(925) 939-2833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:32CENSUS: 20DATE:
12/10/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Ritchie Gonzales, Assistant AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Praveen Singh conducted a Case Management health and safety tele-inspection with Ritchie Gonzales, Assistant Administrator, in relation to the Department receiving a priority 2 complaint. This inspection was conducted via video-conference due to the present shelter in place order by the Governor.

During the tele-inspection, LPA toured the facility, including but not limited to the kitchen, activity room, dining room, and outside areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed locked medication room. LPA observed passageways appeared to be free of obstruction. LPA was informed by Assistant Administrator that everything was in good repair and no disruption to utilities.

No deficiencies cited during inspection. Exit interview conducted and a copy of the report emailed to Administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020
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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