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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601431
Report Date:
06/21/2023
Date Signed:
06/21/2023 09:08:55 PM
Document Has Been Signed on
06/21/2023 09:08 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:
WALNUT CREEK WILLOWS
FACILITY NUMBER:
075601431
ADMINISTRATOR:
DOLLY RIZVI
FACILITY TYPE:
740
ADDRESS:
2015 MT. DIABLO BLVD.
TELEPHONE:
(925) 256-8708
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94596
CAPACITY:
72
CENSUS:
39
DATE:
06/21/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:58 AM
MET WITH:
Marisol Goco
TIME COMPLETED:
07:00 PM
NARRATIVE
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On 06/21/2023 at 10:58 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with and was greeted by "Visitor/Friend", Marisol Goco and explained the purpose of the visit. Marisol lead LPA to the office to set-up laptop. LPA called the Administrator, Cecily Palma, and was advised that she was terminated on yesterday. LPA called the Licensee, Elizabeth "Beth" Cortes and left voice-mail. Beth arrived at the facility approx. 12:03 PM. The facility’s fire clearance was approved for capacity of 72 residents in which all may be Non-Ambulatory.
LPA toured the facility with Medicine Technician (Med-Tech), Daffodale "Daff" Talpas, including but not limited to 4 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 74 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, 109 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 are inaccessible to residents in care.
LPA reviewed 5 residents records. LPA reviewed 9 staff records and 5 of 9 have current first aid training and associated to the facility.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
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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
E BAY DELTA AC/SC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
WALNUT CREEK WILLOWS
FACILITY NUMBER:
075601431
VISIT DATE:
06/21/2023
NARRATIVE
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The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.
At 11:36 AM LPA observed All Purpose Spray in Shower Room
At 11:38 AM LPA observed 2 cans of Lysol and Ajax
At 11:45 AM LPA observed Clorox, Fabuloso, Pine&Glo and 4 bottles of liquids in unlocked door by kitchenette area
At 12:03 PM LPA observed in case of Clorox Bleach, Fabuloso, paint cans in unlocked maintenance closet
At 12:09 PM LPA observed TV, ladders, bikes, mirrors, monitors, wheelchairs outside in the back area behind two sheds
At 12:10 PM LPA observed wood planks outside on the side of building
At 12:12 PM LPA observed mattress, box spring mattress, more wood planks on outside on the side of building
At 12:11 PM LPA observed screen door outside
At 12:13 PM LPA observed brooms, paint bucket, paint brush, rakes, ladders
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/28/2023:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
06/21/2023 09:08 PM
- It Cannot Be Edited
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:
WALNUT CREEK WILLOWS
FACILITY NUMBER:
075601431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by having toxic chemicals inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/22/2023
Plan of Correction
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2
3
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Licensee locked all chemicals. Deficiency cleared during visit
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
06/21/2023 09:08 PM
- It Cannot Be Edited
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:
WALNUT CREEK WILLOWS
FACILITY NUMBER:
075601431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)(3)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute maybe a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: (3) Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in by not having an administrator on the premises which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/21/2023
Plan of Correction
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Licensee has 30 days to hire a new administrator. Licensee will email CCL LIC 9082, LIC 500, LIC 501 and Administrator Certificate by POC Due Date.
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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
4
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Document Has Been Signed on
06/21/2023 09:08 PM
- It Cannot Be Edited
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:
WALNUT CREEK WILLOWS
FACILITY NUMBER:
075601431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in by having bikes, ladders, mirrors, mattresses etc..inaccessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2023
Plan of Correction
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Licensee to have all items: ladders, bikes, wheelchairs, brooms, rakes, toilets removed and submit photos to CCL by POC Due Date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having staff scheduled with CPR Training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2023
Plan of Correction
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Licensee will have First Aid/CPR Training for all staff. Will submit certificates and/or In-Training to CCL by POC Due Date.
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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
5
of
10
Document Has Been Signed on
06/21/2023 09:08 PM
- It Cannot Be Edited
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:
WALNUT CREEK WILLOWS
FACILITY NUMBER:
075601431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by not having a facility manager available when Administrator is absent which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/28/2023
Plan of Correction
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2
3
4
Licensee will submit updated Designation of Facility Responsibility to CCL by POC Due Date.
Type B
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by not having responsible substitute at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/28/2023
Plan of Correction
1
2
3
4
Licensee will submit updated Designation of Facility Responsibility to CCL by POC Due Date.
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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
6
of
10
Document Has Been Signed on
06/21/2023 09:08 PM
- It Cannot Be Edited
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:
WALNUT CREEK WILLOWS
FACILITY NUMBER:
075601431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by having Complaint Poster accessible to which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/28/2023
Plan of Correction
1
2
3
4
Licensee will get a 20x26 poster made at FEDEx and will submit photos to CCL by POC Due Date.
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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
7
of
10
Document Has Been Signed on
06/21/2023 09:08 PM
- It Cannot Be Edited
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:
WALNUT CREEK WILLOWS
FACILITY NUMBER:
075601431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by having record of letter sent to fire department which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/28/2023
Plan of Correction
1
2
3
4
Licensee will send a letter to fire department and will send a copy to CCL by POC Due Date.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not having current Appraisal Needs and Services Plans for residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2023
Plan of Correction
1
2
3
4
Licensee will review and update Appraisals for residents and send copies of residents that are updated to CCL by POC Due Date.
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:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
8
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