<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201273
Report Date: 07/24/2024
Date Signed: 07/24/2024 04:37:58 PM


Document Has Been Signed on 07/24/2024 04:37 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: 27DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ritchie Gonzales, Licensee/AdministratorTIME COMPLETED:
04:50 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 07/24/2024 at 1:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Activities Director, Helen McCauley and explained the purpose of the visit. Staff phoned Licensee/Administrator, Ritchie Gonzales, to inform. Ritchie arrived approximately an hour later. The facility’s fire clearance was approved for 32 (thirty-two) non-ambulatory residents. There is an approved hospice waiver for 10 (ten) residents. Administrator's certificate #6044801740 expires 07/18/2025.

LPA toured the facility with Helen including but not limited to six (6) residents’ apartments, bathrooms, multiple 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 76 and 73 degrees F. LPA 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 109.7, 111.7, 107.0 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.

LPA reviewed 4 residents records. LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility. -

LIC809-C Continued.....
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 079201273
VISIT DATE: 07/24/2024
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
26
27
28
29
30
31
32
LIC809-C Continued...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/31/2024:

LIC 308 Designation of Administrative Responsibility - Reviewed
LIC 309 Administrative Organization - Reviewed
LIC 500 Personnel Report - Reviewed
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance - Reviewed
Administrator's Certificate - Reviewed

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: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2