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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 06/18/2021
Date Signed: 06/18/2021 06:01:56 PM

Document Has Been Signed on 06/18/2021 06:01 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:WALNUT CREEK WILLOWSFACILITY NUMBER:
075601431
ADMINISTRATOR:DOLLY RIZVIFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY: 72CENSUS: 49DATE:
06/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:19 PM
MET WITH:Marilou Ladaban, Facility SupervisorTIME COMPLETED:
08:00 PM
NARRATIVE
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On 06/18/21 at 4:19PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit to address unlocked and open delayed egress door in the north wing while on a tour with facility supervisor during a complaint investigation on 06/18/21.

LPA observed north wing delayed egress door was wide open with no staff attending or closing the open delayed egress doors with dementia residents wandering around the area. LPA advised facility supervisor to train staff in monitoring memory care residents.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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 06/18/2021 06:01 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 06/18/2021 at 04:43 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WALNUT CREEK WILLOWS
FACILITY NUMBER: 075601431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited
CCR
87705(k)(8)

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Care of Persons with Dementia
The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors: Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.
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Faciity supervisor agreed to re-train staff on how to provide proper care and supervision to memory care residents. Proof of training done by a vendorized trainer with staff signatures must be submitted
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This requirement was not met as evidenced by: No staff was attending the memory care residents left in the north wing with the delayed egress door wide open which posed a potential health & safety risk to residents in care.
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to CCLD on or before POC due date.

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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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2021


LIC809 (FAS) - (06/04)
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