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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601180
Report Date: 02/22/2022
Date Signed: 02/22/2022 05:12:17 PM

Document Has Been Signed on 02/22/2022 05:12 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:WELCOME HOME SENIOR RESIDENCE (WALNUT CREEK)FACILITY NUMBER:
075601180
ADMINISTRATOR:CHOU, STEVEFACILITY TYPE:
740
ADDRESS:2421 WASDEN COURTTELEPHONE:
(925) 944-0204
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Clara DelgadoTIME COMPLETED:
05:30 PM
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02/22/2022: Licensing Program Analyst (LPA) James Sampair arrived at 2:15 pm to conduct an infection control annual inspection. LPA was greeted by staff member Jellyn Buenvenida. Administrator (ADM) Clara Delgado is the designated Infection control leader who arrived at 3:45 pm.

LPA explained the purpose of the visit with the ADM. The LPA inspected the facility inside and outside. LPA observed that all of the staff present wore face masks at all times. LPA observed a screening station located near the front entrance with hand sanitizer, a no-touch thermometer, visitor's log, face masks, question concerning and recording of visitor vaccination status for staff, residents, and visitors.

LPA observed COVID-19 signs posted in common areas to promote hand washing and physical distancing. Staff documents temperature and health status for staff and residents on a daily basis. LPA discussed the mitigation plan with the Licensee, as well as their current COVID-19 infection control practices. The ADM has conducted staff training on infection prevention, symptoms, transmission, as well as the proper donning and doffing of PPE.


All of the staff and residents were fully vaccinated. Facility room temperature was maintained at a comfortable temperature. The hot water was within the safe temperature of 105 to 120 degrees Fahrenheit. There were sufficient food and water supplies in the kitchen refrigerators/freezers.

Fire extinguishers were observed fully charged and the Smoke and Carbon monoxide detectors were fully operational.

Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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