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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601579
Report Date: 09/13/2023
Date Signed: 09/13/2023 11:48:55 AM


Document Has Been Signed on 09/13/2023 11:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WALNUT CREEK SENIOR LIVINGFACILITY NUMBER:
075601579
ADMINISTRATOR:DONALD T. HAYFACILITY TYPE:
740
ADDRESS:80 CRAGMONT COURTTELEPHONE:
(925) 939-3635
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:8CENSUS: 6DATE:
09/13/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Caregiver Pamie PalpallatocTIME COMPLETED:
12:15 PM
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On 09/13/2023 at 10:45 AM, Licensing Program Analyst (LPA) J. Sampair conducted a Plan of Correction (POC) inspection. Upon entry into facility, LPA explained the purpose of the visit with Caregiver Pamie Palpallatoc.

This visit was prompted by the 04/05/2023 POC visit concerning the Licensee's failure to provide documentation to the LPA that the citation from 03/27/2023 had been corrected. When LPA entered facility, he observed that the Licensee had replaced the key operated locks facing inside with locks that are operated without a key.

No citations were issued during this visit.

Exit interview conducted with Caregiver Pamie Palpallatoc. A copy of this report provided to Licensee via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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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