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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601579
Report Date: 01/29/2026
Date Signed: 01/29/2026 06:42:49 PM

Document Has Been Signed on 01/29/2026 06:42 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WALNUT CREEK SENIOR LIVINGFACILITY NUMBER:
075601579
ADMINISTRATOR/
DIRECTOR:		DONALD T. HAYFACILITY TYPE:
740
ADDRESS:80 CRAGMONT COURTTELEPHONE:
(925) 939-3635
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 8CENSUS: 8DATE:
01/29/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Caregiver Pamie PalpallatocTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On 1/29/2026 at 11:45 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Case Management Annual Continuation Inspection. Upon entry, the LPA stated the purpose of the visit to Caregiver Pamie Palpallatoc. Shortly thereafter, the LPA stated the purpose of the visit to Administrator Donald Hay by phone.

The LPA briefly toured the facility, reviewed facility documents, and reviewed 5 staff records.

3 Type A citations, 6 Type B citations, and $1,000 in civil penalties issued during the inspection.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D. Failure to submit Proof of Corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

The Required Annual Inspection is not complete. The LPA will return unannounced to complete the annual inspection.

Exit interview conducted and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2026
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 01/29/2026 06:42 PM - It Cannot Be Edited


Created By: James Sampair On 01/29/2026 at 12:41 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 SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(1)
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: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications . . . and meetings of resident and family groups.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. A monitor displaying videos of 9 resident rooms was located in the living room next to the television for anyone to see and without a wiaver of the personal rights of residents for the facility, which poses an immediate personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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On or before the due date, the Licensee shall remove the monitor and stop the use of all video recording in all residents' rooms or any other private areas within the facility.
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review . . . shall prior to working . . . in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Staff S4 was not fingerprint cleared, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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The Licensee shall immediately remove S4 from the facility and not allow them to return until they are fingerprint cleared and associated with this facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2026 06:42 PM - It Cannot Be Edited


Created By: James Sampair On 01/29/2026 at 05:23 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 SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. On 1/23/2026, staff members S1 and S2 complained of the facility being understaffed. On 1/29/26 staff member S3 complained of being understaffed, because she is being asked to do not only caregiving tasks but also administrative tasks, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2026
Plan of Correction
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On or before the due date, the Licensee shall hire 1 additional staff member to work on administrative duties only.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2026 06:42 PM - It Cannot Be Edited


Created By: James Sampair On 01/29/2026 at 05:23 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 SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. On 1/23/2026, staff members S1 and S2 complained of being understaffed, because S3 was on vacation and the Licensee did not have enough staff to cover, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2026
Plan of Correction
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On or before the due date, the Licensee shall hire 1 additional staff member to work on administrative duties only.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above. 0 of 5 staff had the training in 2025, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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On or before the due date, the Licensee shall have all staff complete their training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2026 06:42 PM - It Cannot Be Edited


Created By: James Sampair On 01/29/2026 at 05:23 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 SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. 0 of 1 new employees received medication training which poses a potential health risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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On or before due date, Licensee shall have all staff assists residents with medications complete the medication training.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, completing 1 of 4 drills during the past year, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2026
Plan of Correction
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On or before due date, the Licensee shall conduct a quarterly drill and schedule the rest of the drill during the coming year.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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Created By: James Sampair On 01/29/2026 at 05:30 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 SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. . .

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. On 1/23/2026, 9 residents were residing at the facility, which /posed a potential health and safety risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee had 9 residents when LPA conducted the first visit on 1/23/2026. As of 1/29/2026, there are 8 residents. The Licensee shall not add another resident until their expansion of the facility has been licensed to operate with more than the 8 for which it is currently licensed to operate.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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2
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2026 06:42 PM - It Cannot Be Edited


Created By: James Sampair On 01/29/2026 at 05:51 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 SENIOR LIVING
FACILITY NUMBER: 075601579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete four hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. 0 of 6 employees received medication training which poses a potential health risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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2
3
4
On or before due date, Licensee shall have all staff assists residents with medications complete the medication training.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
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