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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:53:43 PM

Document Has Been Signed on 05/08/2024 04:53 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/
DIRECTOR:		CORTES, ELIZABETHFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY: 72CENSUS: 44DATE:
05/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:55 PM
MET WITH:ELIZABETH CORTES, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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While at the facility for another reason, Licensing Program Analyst (LPA) Carol Fowler learned that a resident at the facility has a private care giver that was not finger print cleared or associated to the facility. Staff 1 (S1) has been working at the facility since 12/2023. S1 has been finger print cleared as of 5/4/2024 but is not associated to the facility.

R1's personal caregiver, S1) who visits R1 and provides activities of daily living (ADL) care, five (5) days a week from 9:00am to 12:00pm and 5:00pm to 7:00pm.

Administrator admitted to not having S1 finger print cleared and associated to the facility.

Deficiencies are being cited in violation of California Code of Regulations (see 809D).
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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 05/08/2024 04:53 PM - It Cannot Be Edited


Created By: Carol Fowler On 05/08/2024 at 04:31 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: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
1569.17

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Fingerprints and criminal records of individuals in contact with clients...record exemption from the State Department of Social Services before his or her initial presence in a residential care facility for the elderly.
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Administrator will read the Regulation and send self certification of understanding to Community Care Licensing (CCL) by POC date. In addition, licensee will not allow any individual to work,
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reside, or volunteer prior to being finger print cleared and associated.
Administrator will also forward a copy of S1 clearance and association to CCLD by POC 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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
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