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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200580
Report Date: 07/08/2021
Date Signed: 07/08/2021 05:14:14 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:
07/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Katelyn Wilson, Resident Care DirectorTIME COMPLETED:
05:30 PM
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On 07/08/21 at 4:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with resident care director. LPA observed administrator was not available during visit. LPA spoke with administrator on the phone who authorized the resident care director to sign the reports. LPA observed 3 staff wearing face masks during visit. LPA observed 12 residents relaxing in the visitation room with two staff wearing a face masks. Facility has a completed mitigation plan in place dated 06/01/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with resident care director as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with staff entering information on the visitor's log and using the no touch temperature probe for daily symptom screening (+/-) temperature & symptom check. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors.

LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Facility has living areas with furniture spaced six feet apart for social distancing among residents.

Continued on next page LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HEATHERWOOD MEMORY CARE
FACILITY NUMBER: 079200580
VISIT DATE: 07/08/2021
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All staff and residents have been fully vaccinated since February 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Infection control designated leader is the administrator. Emergency food supplies were observed stored in locked storage room. Medications were observed locked in medication carts outside the medication room. Facility room temperature was maintained at 74 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged. Smoke and Carbon monoxide detectors were operational. LPA observed communal dining area with tables six feet apart.

Updated copies of the following documents will be emailed to LPA by resident director on 07/12/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to resident director.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC809 (FAS) - (06/04)
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