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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202821
Report Date: 05/22/2023
Date Signed: 05/22/2023 04:52:35 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230420093904
FACILITY NAME:WILLOW OAKS SENIOR LIVINGFACILITY NUMBER:
435202821
ADMINISTRATOR:AGNES TEODOROFACILITY TYPE:
740
ADDRESS:1573 WILLOW OAKS DR.TELEPHONE:
(408) 914-1147
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
05/22/2023
UNANNOUNCEDTIME BEGAN:
04:02 PM
MET WITH:Agnes TeodoroTIME COMPLETED:
04:33 PM
ALLEGATION(S):
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9
Facility staff did not take proper measures to eradicate scabies at facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted a complaint investigation visit to deliver the investigation finding and met with Assistant Administrator (AADM) Agnes Teodoro.

During the course of the investigation, LPA toured the facility, reviewed resident records and interviewed ADM Irish Ladwig. While touring the facility and reviewing client roster, LPA observed that residents name was not on the client roster.

During the interview with ADM Irish Ladwig, LPA asked if Willow Oaks has had any residents treated or sent to the hospital for scabies. Licensee responded that Willow oaks has no resident with scabies symptoms. LPA asked if R'1 lives in Willow Oaks. ADM stated R'1 has never been a resident at Willow Oaks. With the information provided by the facility, the complaint is unfounded based on the fact that R'1 does not live in Willow Oaks.
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Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20230420093904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WILLOW OAKS SENIOR LIVING
FACILITY NUMBER: 435202821
VISIT DATE: 05/22/2023
NARRATIVE
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This Department has investigated the above allegation. Based on observation, interviews and records review, the Department has determined that the allegation is UNFOUNDED, meaning that the allegation did not occur.

This report was reviewed with AADM and a signed copy of the report was provided.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2