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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 11/26/2024
Date Signed: 12/17/2024 06:12:00 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
11/04/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241104122537
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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Licensee does not ensure that resident's room is adequately cleaned.
INVESTIGATION FINDINGS:
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This is an amendment to an original 9099 report issued on 11/26/2024.

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 findings of above allegation. LPA explained the purpose of the visit with Administrator.

During investigation, LPA interviewed three (3) residents (R) R1, R2, R3, one (1) staff (S) S1, and complainant. LPA obtained and reviewed documents including…..

LIC9099-C Continued...
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 2
Control Number 15-AS-20241104122537
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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This is an amendment to an original LIC9099-C report issued on 11/26/2024.

LIC9099-C (Page 2)

Allegation: Licensee does not ensure that resident's room is adequately cleaned.
Finding: Unsubstantiated

Based on interviews with R2, R3, and R4 residents' rooms are cleaned daily. R2, R3 and R4 stated that the housekeeping staff thoroughly sweeps, mops and cleans their rooms daily. R2 stated that the housekeeper thoroughly sweeps, mops and cleans their bathroom two (2) times a week. R1's bedroom and bathroom is scheduled to be cleaned two (2) times a week.

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: 2 of 2