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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601256
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:15:05 PM


Document Has Been Signed on 09/29/2023 03:15 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:WILLOW CREEK ALZHEIMER'S & DEMENTIA CARE CENTERFACILITY NUMBER:
015601256
ADMINISTRATOR:CARSON, ELIZABETH MFACILITY TYPE:
740
ADDRESS:22424 CHARLENE WAYTELEPHONE:
(510) 889-1300
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:49CENSUS: 34DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Rohini Chand, Resident CoordinatorTIME COMPLETED:
03:35 PM
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On 9/29/23 at 9:25AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced required 1-year inspection and met with Rohini Chand resident coordinator. LPA explained reason for visit and toured the facility inside and out including but not limited to facility kitchen, hallway, activity area, dining room, bathrooms, outside area, and resident rooms. The hot water temperature in hallway bathroom measured at 111.4 degrees Fahrenheit and resident room #7 measured at 107.7 degrees Fahrenheit. The outside area is free of obstruction and bodies of water.

Medications are centrally stored in a locked medication room that are only accessible by medication technicians. Facility freezer temperature was observed at 0 degrees Fahrenheit and refrigerator temperature was observed at 40 degrees Fahrenheit.

Facility smoke and carbon monoxide detectors were observed as operational. The sprinkler system was last inspected on 7/27/23. Fire drill was last conducted on 7/2023. The fire extinguisher was last inspected on 3/2022. The first aid kit was observed to be complete.

During record review, LPAs reviewed a sample of 5 staff records and observed 5 of 5 have health screening with TB test on file, and 5 residents have physician's report and care plans up to date.

LPA reviewed 5 resident medications. LPA observed all resident medications were accurate with their doctor's orders.

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: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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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