079201161-7-29-2026-15-AS-JSAR-DWFNC3-20260729102004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201161
Report Date: 07/28/2026
Date Signed: 07/29/2026 10:26:29 AM

Document Has Been Signed on 07/29/2026 10:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	WALNUT CREEK CARE HOME		FACILITY NUMBER:	079201161
ADMINISTRATOR/ DIRECTOR:	JAIN, ASHA		FACILITY TYPE:	740
ADDRESS:	2562 VENADO CAMINO		TELEPHONE:	(925) 287-8994
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY: 6		CENSUS: 5	DATE:	07/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Administrator Asha Jain		TIME VISIT/ INSPECTION COMPLETED:	07:45 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 07/28/2026, at 10:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Required 1 Year inspection. Upon arrival, the LPA explained the purpose of the visit to Caregiver Rommel Dimzon. Administrator (ADM) Asha Jain arrived at approximately 10:50 AM. The LPA and ADM toured the community inside and outside. The tour of the community included, but was not limited to, residents’ rooms, bathrooms, the kitchen, common areas, the garage, and the backyard. The community was clean, appropriately furnished, and well lit. There are no bodies of water on the grounds of the community. The interior passageways of the community were free from obstructions. The residents’ bathrooms are equipped with grab bars and slip-resistant mats. The temperature of the two refrigerators were measured to be below 40 degrees and the two freezers below 0 degrees Fahrenheit. The maximum hot water temperature was measured at 114 degrees Fahrenheit. There is more than the required minimum of a 7-day supply of nonperishable foods and a 2-day supply of perishable foods on hand. The centrally stored medication cabinets were locked. At approximately 1:40 PM, the inside temperature was measured at 78 degrees Fahrenheit in the kitchen. Continued on LIC 809-C . . .

Lizette Francisco
James Sampair
	DATE: 07/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 07/29/2026 10:26 AM - It Cannot Be Edited

Created By: James Sampair On 07/28/2026 at 05:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK CARE HOME	FACILITY NUMBER: 079201161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Sharps in kitchen drawer with broken lock, detergents and cleaning solutions, including Clorox liquid bleach with no lid, are stored in no cabinet and in unlocked cabinets in the backyard and in the garage, which poses an immediate safety risk to persons in care.
	POC Due Date: 07/29/2026
	Plan of Correction
1 2 3 4	The deficiencies were corrected during the inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:

	James Sampair
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2026 10:26 AM - It Cannot Be Edited

Created By: James Sampair On 07/28/2026 at 05:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK CARE HOME	FACILITY NUMBER: 079201161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Two 10-foot segments of the backyard fence had been removed. No temporary screen had been installed to stop residents with a dementia diagnosis from walking directly into a highly travelled street, Ygnacio Valley Boulevard, where the speed limit is 45 miles an hour, which poses a potential safety risk to persons in care.
	POC Due Date: 08/03/2026
	Plan of Correction
1 2 3 4	Licensee has agreed to install temporary screens to block residents from walking through the openings in the fence.

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Two of the screen doors have holes in them and multiple window screens have spider webs and are full of dust, which poses a potential health risk to persons in care.
	POC Due Date: 08/31/2026
	Plan of Correction
1 2 3 4	The Licensee has agreed to clean and repair the window screens.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:

	James Sampair
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK CARE HOME	FACILITY NUMBER: 079201161
	VISIT DATE: 07/28/2026

NARRATIVE

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. . . Continued from LIC 809

The LPA observed the required postings in the community. The smoke and carbon monoxide detectors were operational. The fire extinguisher was last serviced on 08/28/2025. The Emergency Disaster Plan was reviewed by the ADM on 07/28/2026.

Emergency and disaster drills were conducted for the sufficient number of staff each quarter and the most recent one was conducted on 07/09/2026. The first aid kit was observed to be complete. Staff were trained to dispense medications directly from the original container to residents.

The liability insurance is current through 09/19/2026. An administrator is not on site more than the minimum of 20 hours a week to ensure proper business operations are being conducted.

The LPA reviewed community records, 5 resident records, and 5 staff records.

1 Type A, 5 Type B, and 6 Technical Violations were issued during this inspection.

Exit interview conducted and a copy of this report provided.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D. Failure to submit Proof of Corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

NAME OF LICENSING PROGRAM MANAGER: Lizette Francisco
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2026 10:26 AM - It Cannot Be Edited

Created By: James Sampair On 07/28/2026 at 06:55 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK CARE HOME	FACILITY NUMBER: 079201161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) ... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff records reviewed, which poses a potential safety risk to persons in care.
	POC Due Date: 08/03/2026
	Plan of Correction
1 2 3 4	The Licensee has agreed to have the 2 staff complete their first aid training before providing direct assistance to residents with the activities of daily living again.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:

	James Sampair
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

Page: 13 of 13

Document Has Been Signed on 07/29/2026 10:26 AM - It Cannot Be Edited

Created By: James Sampair On 07/28/2026 at 05:39 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK CARE HOME	FACILITY NUMBER: 079201161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The handle to flush the shared toilet is broken, which poses/posed a potential health risk to persons in care.
	POC Due Date: 08/03/2026
	Plan of Correction
1 2 3 4	The Licensee has agreed to repair the toilet handle.

Type B

Section Cited

CCR

87307(d)(4)

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. In the backyard, the end segment of the railing on a concrete incline and on a segment of the wooden deck, which poses a potential safety risk to persons in care.
	POC Due Date: 08/31/2026
	Plan of Correction
1 2 3 4	The Licensee has agreed to repair the railing.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:

	James Sampair
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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