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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200580
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:48:23 PM


Document Has Been Signed on 03/13/2023 03:48 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:
03/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Administrator, Ritchie GonzalesTIME COMPLETED:
03:55 PM
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On 3/13/23 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit regarding an Unusual Incident Report for R1. LPA met with administrator, Ritchie Gonzales and informed him the reason for the visit.

During visit LPA interviewed administrator, Ritchie Gonzales at the facility and Katelyn Wilson, Assistant Administrator via telephone. On 2/21/23 R1 was transported to Kaiser Walnut Creek (non-emergency) due to a fall. R1 was admitted to the hospital on 2/21/23 and later transferred to Kaiser Oakland for surgery. R1 returned to the facility on 3/7/23. Currently R1 uses a wheelchair for ambulation. R1 is awaiting an evaluation from Home Health Physical Therapist( PT) to be cleared to ambulate independently.

At 3:00 p.m., LPA observed R1 in the activity room sitting in a recliner listening to music with facility staff by his side. LPA later observed R1 in the wheelchair being transported by staff to the bathroom. R1 was alerted and cheerful.

LPA discussed the facility's plans to assist R1 in securing a Home Health Agency to meet his current needs. Facility understands that care and supervision for R1 would continue until R1 is evaluated by Home Health PT.

No deficiencies cited during visit, Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023
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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