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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200580
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:28:05 PM


Document Has Been Signed on 06/22/2023 04:28 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
E BAY DELTA AC/SC, 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: 26DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Katelyn Wilson, Resident Care CoordinatorTIME COMPLETED:
03:30 PM
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On this day at around 9:30 am, Licensing Program Analysts (LPAs) L. Alexander and Luisa Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Resident Care Coordinator (RCC) Katelyn Wilson and explained the purpose of the visit.

LPAs with RCC toured the facility including but not limited to 5 residents apartments, bathrooms, activity area, kitchen, courtyard and common areas. The facility has an approved fire clearance for 32 non ambulatory residents, 5 of which may be bedridden in Rooms 1, 2 and 11. Facility has an approved hospice waiver for 10 residents. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 108, 110.5, 109 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

There are multiple fire extinguishers observed that were last inspected on 07/28/2022. Smoke detectors and carbon monoxide were tested and observed 03/06/23. The last fire drill was conducted on 06/09/23.

***continuation on Lic 809C***
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HEATHERWOOD MEMORY CARE
FACILITY NUMBER: 079200580
VISIT DATE: 06/22/2023
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First aid kit was reviewed and observed complete. Medication Administration Record (MAR) and medications were reviewed with RCC.

LPAs reviewed 6 resident files and 5 staff files. LPAs interviewed 1 resident and 5 staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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