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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001963
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:41:33 PM

Document Has Been Signed on 09/11/2024 03:41 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WILLOW GLEN CARE CENTERFACILITY NUMBER:
515001963
ADMINISTRATOR/
DIRECTOR:		ANGIE KARISFACILITY TYPE:
740
ADDRESS:1547 PLUMAS COURTTELEPHONE:
(530) 751-9900
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 60CENSUS: 59DATE:
09/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:05 PM
MET WITH:Cindy LujenTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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LPA Hiratsuka conducted this unannounced case management visit in response to several residents leaving without supervision.

The occurrences were 09/09/2024, and LPA was informed the resident is returning this evening; 08/23/2024, and returned; 05/14/2024, resident returned,\; one resident who left twice in May 2024, and one who left in April 2024. All residents were deemed to not be able to leave the facility unassisted by their physicians. The residents were not injured and they all returned. Most of the residents here have high functioning mental capabilities and are all physically ambulatory. From the amount of residents who were able to leave the facility without notice and without permission it has been determined the facility shall submit a written plan to address this issue.


CA Health and Safety Code 1569.312 (e) states, "Every facility required to be licensed under this chapter shall provide at least the following basic services; "Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being."

Because multiple residents have made it out of the facility without anyone noticing, the following deficiency was cited. The following deficiency is cited on LIC 809D and cited from the California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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Document Has Been Signed on 09/11/2024 03:41 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 09/11/2024 at 03:27 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WILLOW GLEN CARE CENTER
FACILITY NUMBER: 515001963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/27/2024
Section Cited

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Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being
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Licensee failed this because multiple residents have left the facility without permission and without notice. This poses a potential health and safety risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
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