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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 03/05/2025
Date Signed: 03/05/2025 05:45:23 PM

Document Has Been Signed on 03/05/2025 05:45 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
E BAY DELTA AC/SC, 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: 53DATE:
03/05/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Lynette Sandoval, Administrative AssistantTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 03/05/2025 at 4:30 pm Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Case Management visit. LPA met with Administrative Assistant, Lynette Sandoval. Lynette phoned Administrator, Elizabeth Cortes to inform.

While LPAs L. Alexander and K. Nguyen was at the facility for a complaint investigation (#15-AS-20250224153947), the following deficiency was observed. LPAs observed that resident, R1, has a “Personally Operated Video Surveillance with Audio Recording” in a shared bedroom with R2. LPAs reviewed R2’s records that showed that the camera with audio is being used without the written and documented consent of the resident or the resident’s responsible party.



The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/05/2025 05:45 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 03/05/2025 at 03:59 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: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
87468.2(a)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Administrator will read regulation and self-certify understanding this regulation moving forward. In addition, Administrator will have to ensure and attest that the camera does not obtain audio by sending a detailed letter to CCLD by POC due date.
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Based on observation and interview the licensee did not comply with the section cited above in by ensuring that camera with audio does not violate a residents' right to privacy and dignity as required by existing regulations. Including but not limited to all clients and residents maintain privacy and dignity rights that could be violated by negligent and/or abusive surveillance practices which poses 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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