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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200580
Report Date: 09/01/2022
Date Signed: 09/01/2022 04:59:06 PM


Document Has Been Signed on 09/01/2022 04:59 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: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: 24DATE:
09/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:39 PM
MET WITH:Ritchie Gonzalez, AdministratorTIME COMPLETED:
05:40 PM
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On 09/01/22 at 4:39PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving a priority 1 complaint.

During the health and safety check, LPA observed a total of 6 staff members and 24 residents at the facility. LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, and common areas. LPA observed COVID signages in the front entrance, hallways, bathrooms and visitation areas. Screening station was observed to have the no touch temperature probe, additional masks, gloves and hand sanitizers. LPA observed 14 residents in the activities room with 4 staff assisting them with various activities. Other residents were observed relaxing inside their bedrooms. PPEs, staffing, food and paper supplies were observed sufficient. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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