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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:01:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240903114802
FACILITY NAME:WALNUT CREEK WILLOWSFACILITY NUMBER:
075601431
ADMINISTRATOR:CORTES, ELIZABETHFACILITY TYPE:
740
ADDRESS:2015 MT. DIABLO BLVD.TELEPHONE:
(925) 256-8708
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:72CENSUS: 49DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elizabeth Cortes, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not safeguard resident's personal possessions.
INVESTIGATION FINDINGS:
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On 11/26/2024 at xx:xx AM/PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Licensee/Administrator, Elizabeth Cortes to deliver findings of above allegation. LPA explained the purpose of the visit with Administrator, Elizabeth Cortes.

During the course of the investigation, LPA interviewed three (3) residents (R) R1, R2, R3, two (2) staff (S) S1, S2, and complainant. LPA obtained and reviewed documents including staff roster and staff schedule.

LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20240903114802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/26/2024
NARRATIVE
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LIC9099-C (Page 2)

Allegation: Staff do not safeguard resident's personal possessions.
Finding: Unsubstantiated

On 09/30/2024, the LPA interviewed R1 that stated they ordered three (3) banana bread muffins online on 09/03/2024. R1 stated that they left the muffins in a basket next to their bed. R1 stated that they ate one (1) of the muffins so that left them with two (2) muffins. R1 stated that the last person in the room was S2. R1 stated that S1 spoke with S2 regarding the missing banana bread muffin and that S2 denied that they took anything and that they did not touch anything in R1’s room. R1 stated that S1 replaced the muffin.

R1 further stated that on 09/21/2024 they bought three (3) bottles of coconut water that they kept in the locked refrigerator in the back kitchen. R1 stated that one (1) of their bottled coconut waters were missing and one (1) of their yogurts was also missing from the refrigerator. R1 stated that they labeled their food items with their name and date and that other residents use this same refrigerator.

On 10/07/2024, the LPA interviewed S1 and S2. S1 stated that they spoke with S3 and that S3 said that they did not touch nor take anything in R1’s room. S1 stated that they went to the store and bought R1 another banana bread muffin to replace the missing muffin. S2 stated that residents can place their personal food items in the locked refrigerator and that no one has access to the refrigerator. S2 stated that only kitchen staff are allowed in the kitchen and when a resident wants their food, they can ask the staff to get the item.

LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240903114802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/26/2024
NARRATIVE
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LIC9099-C (Page 3)

On 11/08/2024, the LPA interviewed R2 and R3 that stated that they have not had anything missing from the facility and nothing missing from out the refrigerator if they used it.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3