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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601431
Report Date: 04/10/2025
Date Signed: 04/10/2025 01:09:02 PM

Document Has Been Signed on 04/10/2025 01:09 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: 49DATE:
04/10/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Lynette Sandoval, Administrative Assistant TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 04/10/2025 at 11:40 AM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management. LPA met with Lynette Sandoval, Administrative Assistant, and explained the purpose of the visit.

LPA L. Alexander conducted Complaint visits on 03/05/2025, 11/26/2024, and cited for deficiencies. The Plan of Correction (POC) original due dates were 03/21/2025, 12/30/2024 and 12/20/2024. LPA conducted a Case Management visits on 03/06/2025, and 03/05/2025, in which there were deficiencies cited. The POC due dates were 03/31/2025 and 03/13/2025.

LPA was unable conduct a POC visits for deficiencies cited during the 10 day time frame.
Deficiencies not cleared will be re-cited with a new POC due date. Repeat Violations will be assessed civil penalties of $250.00 each x 6 = $1,500.00 today.

Deficiencies not cleared
  • CCR 87555(b)(25)
  • CCR 87468.2(a)
  • CCR 87468.2(a)(1)
  • CCR 87307(c)
  • CCR 87468.1(a)(1)(b)(5)
  • CCR 87224(a)

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

Exit interview conducted. A copy of this report, LIC421FC and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/10/2025 01:09 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 04/10/2025 at 11:13 AM
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: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2025
Section Cited
CCR
87555(b)(25)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
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Administrator agreed to remove the cleaning disinfectant products and send a photo. In addition, read the regulation and self-certify understanding the regulation moving forward. POC documents will be sent to CCLD by POC due date.
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Based on observation, the licensee did not comply with the section cited above in by not storing cases of Clorox Bleach and bottles of Fabuloso Multi-Purpose Cleaner in a area separate from food supplies which poses a potential health and safety risk to persons in care.
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Repeat Violation Immediate Civil Penalty $250.00
Type B
04/17/2025
Section Cited
CCR87468.2(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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Repeat Violation Immediate Civil Penalty $250.00
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2025 01:09 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 04/10/2025 at 11:49 AM
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: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2025
Section Cited
CCR
87468.2(a)(1)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...87468.1, Personal Rights of Residents in All Facilities,...residential care facilities for the elderly shall have all of the following personal rights:
(1) To have a reasonable level of personal privacy in accommodations...

This requirement is not met as evidenced by:
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Administrator agrees to conduct In-service training with all staff on personal rights including but not limited to phones devices. Training-sign in sheet and synopsis of the training topic will be submitted 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 violating R1's personal rights to privacy including but not limited to picking up R1's phone and looking at messages when they are not present which poses a potential safety or personal rights risk to persons in care.
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Repeat Violation Immediate Civil Penalty $250.00
Type B
04/17/2025
Section Cited
CCR87307(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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Repeat Violation Immediate Civil Penalty $250.00
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2025 01:09 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 04/10/2025 at 11:53 AM
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: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2025
Section Cited
CCR
87468.1(a)(1)(b)(5)

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87468.1 Personal Rights of Residents in All Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. (5) Willfully and repeatedly fail to use a resident’s preferred name or pronouns after being informed of the resident’s preferred name or pronouns in a clear manner.

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 observation and interview, the licensee did not comply with the section cited above in by not according dignity and respect with bathing, showering, toileting, and addressing residents by their preferred names and pronouns which poses a potential health, safety or personal rights risk to persons in care.
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Repeat Violation Immediate Civil Penalty $250.00
Type B
04/17/2025
Section Cited
CCR87224(a)

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87224 Eviction Procedures

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)

This requirement is not met as evidenced by:
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The licensee will read regulation 87224 and submit self-certification that it has been read, understood and they will abide going forward to CCLD by POC due date.
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Based on interviews and record review the licensee did not comply with the section cited above in by serving R1 with an appropriate eviction notice after deciding not to accept R1 back to the facility once R1 was discharged from the hospital ER which posed a potential health and safety risk and personal rights to persons in care.
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Repeat Violation Immediate Civil Penalty $250.00
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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