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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600012
Report Date: 08/19/2022
Date Signed: 08/19/2022 04:45:30 PM


Document Has Been Signed on 08/19/2022 04:45 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 GLEN RESIDENCEFACILITY NUMBER:
075600012
ADMINISTRATOR:VILLAREAL, LEVIFACILITY TYPE:
740
ADDRESS:2040 MENDOCINO DRIVETELEPHONE:
(925) 458-5057
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY:5CENSUS: 1DATE:
08/19/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Levi Villareal, LicenseeTIME COMPLETED:
03:30 PM
NARRATIVE
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On 8/19/2022, at 1:00PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPA met with Levi Villareal, Licensee, and explained the purpose of the visit.

Facility has the following deficiencies that were not cleared:

  • 87632(a), LPA have not received documents to request a hospice waiver from Licensee after annual inspection visit 8/11/2022.
  • 87405(a), LPA have not received plan on what facility would do until they hire an Administrator or recertify as Administrator, after annual inspection visit 8/11/2022. LPA gave 30-days (9/19/2022) for Administrator new hire.
  • 87506(a), LPA did not receive self-certification stating that R1's file was complete and on today's date R1's file is still not complete after annual inspection visit 8/11/2022.

Civil Penalties for 87632(a) in the amount of $700 assessed immediately for the period of 8/13/2022 - 8/19/2022.
Civil Penalties for 87405(a) in the amount of $100 assessed immediately for the period of 8/19/200 - 8/19/2022.
Civil Penalties for 87506(a) in the amount of $100 assessed immediately for the period of 8/19-2022 - 8/19/2022.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WILLOW GLEN RESIDENCE
FACILITY NUMBER: 075600012
VISIT DATE: 08/19/2022
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Continued from LIC809.

Civil Penalties in the total amount of $900 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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