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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 04:46:08 PM

Substantiated


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
09/23/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240923114538
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:
05:00 PM
ALLEGATION(S):
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Staff do not accord resident privacy.
INVESTIGATION FINDINGS:
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On 11/26/2024 at 12:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Administrator, Elizabeth Cortes to deliver the findings of above allegation. LPA explained the purpose of the visit with Administrator.

During the course of the investigation, LPA interviewed two (2) staff (S) S1, S2, and one (1) resident (R) R1. The LPA obtained the following documents from the facility: resident’s roster, staff roster, shower schedule and physician’s report.

LIC9099-C Continued...

Substantiated
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-20240923114538
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 accord resident privacy.
Finding: Substantiated

On 09/30/2024, the LPA interviewed R1. R1 stated that on 09/22/2024 they were in the shower room taking a shower when S1, a male caregiver, “barged” in the shower room just to get a cup of water. R1 stated that S1 said, “Hi,” got a cup of water and then left out the shower room. R1 stated that they were naked and had to cover up their chest. R1 stated that they felt very uncomfortable. R1 stated that there was another male staff sitting on the chair outside the shower room looking down at their phone. R1 stated that they were only in a hospital gown and that they asked the male staff if they could move. The male staff got up and stood at the counter across from the shower room but was still looking at their phone.

On 10/07/2024, the LPA interviewed S1 and S4. S1 stated that they are a caregiver in the South Wing, and their duties are to change diapers, grooming (trimming resident’s facial hair, giving haircuts), feeding residents and giving residents showers. S1 stated that they couldn’t find a towel and that towels are only located in the shower room. S1 stated that they came to the shower room to grab a towel and thought that the shower room was empty. S4 stated that S3 was on their phone because they were clocking in to start their shift.

Based on LPA’s observations and interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights 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: 2 of 3
Control Number 15-AS-20240923114538
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2024
Section Cited
CCR
87307(c)
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87307 Personal Accommodations and Services
(c) Individual privacy shall be provided in all toilet, bath and shower areas.

This requirement is not met as evidenced by:
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Administrator agreed to conduct In-Service Training with staff/caregivers and send copy of sign-in sheet to CCLD by POC due date.
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Based on interviews, licensee did not comply with the section cited above in by not ensuring R1’s privacy while showering which posed a potential health, safety or personal rights risk to persons in care.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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