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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201273
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:29:06 PM


Document Has Been Signed on 06/22/2023 04:29 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:
079201273
ADMINISTRATOR:GONZALES, RITCHIEFACILITY 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Katelyn Wilson, Assistant AdministratorTIME COMPLETED:
05:15 PM
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On 06/22/2023 at 4:30PM, Licensing Program Analysts (LPAs) L. Alexander and Luisa Fontanilla conducted a face to face Component III presentation with Assistant Administrator Katelyn Wilson.

LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed participant gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted and a copy of 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
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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