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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200580
Report Date: 05/20/2022
Date Signed: 06/15/2022 04:57:34 PM


Document Has Been Signed on 06/15/2022 04:57 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: 25DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ritchie Gonzales, Administrator AssistantTIME COMPLETED:
02:15 PM
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On 5/20/2022 at 1:00 PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Assistant, Ritchie Gonzales and explained the purpose of the visit. The facility’s fire clearance was approved for 32 residents.

LPA toured the facility with Ritchie Gonzales including but not limited to 7 residents bathrooms, activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. 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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/27/2022:

-LIC500 Personnel Report

-LIC308 Designation of Administrative Responsibility

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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