<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200580
Report Date: 11/03/2022
Date Signed: 11/03/2022 03:24:32 PM


Document Has Been Signed on 11/03/2022 03:24 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:
11/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ritchie Gonzales, AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/3/2022 at 2:30PM, Licensing Program Analysts (LPAs) G. Luk and L. Alexander arrived unannounced to conduct a case management visit regarding eviction of R1. LPAs met with administrator, Ritchie Gonzales and informed him the reason for the visit.

During visit, LPAs observed R1 resides in room 1 and is currently at the facility. LPAs were informed that facility is currently providing care and supervision to R1. LPAs obtained documents including correspondence with family members, current physician's report, and correspondence with R1's doctor.

LPAs discussed the facility's plans to assist R1 in finding new placement. Facility understands that care and supervision for R1 would continue until R1 is relocated.

LPAs may return on a later date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1