Willow Creek Alzheimer's & Dementia Care Center

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Type of visit: Required - 1 Year

On 09/15/2026 at 2:40 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Babita Dhawan, Administrator and explained the purpose of the visit. LPA toured the facility including but not limited to 6 resident rooms, bathrooms, activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 108 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/12/2026. Emergency Disaster Plan was last posted on 07/07/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 09/01/2026. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 15, 2026

Type of visit: Case Management - Health Checks

On 07/17/2026 at 11:15 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint with the control number (#15-AS-20260716121322.) LPA met with Administrator Babita Dhawan, Administrator and explained the purpose for the visit. LPA observed residents sitting in common area, activity room, and dining area. During the health and safety check, LPA toured the building with the Administrator. LPA toured the common areas, bathrooms, bedrooms and outdoor area. LPA observed and measured a comfortable water temperature at 117.5 degrees Fahrenheit. No deficiencies were cited today. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 17, 2026

Type of visit: Required - 1 Year

On 08/27/2025 at 10:10 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Elizabeth Carson and explained the purpose of the visit. LPA toured the facility including but not limited to 5 residents’ rooms, bathrooms, activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 05/05/2025. Emergency Disaster Plan was last posted on 01/01/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/07/2025. LPA reviewed 6 residents records and 6 staff records, and all were complete. LPA also reviewed a sample of 6 resident’s medications. The following documents were reviewed during the visit: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 27, 2025

Allegation investigated: Resident sustained unexplained injury while in care. Facility staff did not seek medical attention of residents in care.

On 05/16/2025 at 2:10 PM, Licensing Program Analysts (LPAs) Ardalan Gharachorloo and Greg Clark arrived unannounced to deliver findings in regard to the allegations above. LPAs met with VP of Operations, Elizabeth Carson and explained the purpose of the visit. During the course of the investigation LPsA interviewed W1, S1-S5 and toured the facility’s memory care unit and reveiwed documents related to R1's care. LPA was unable to interview because R1 no longers lives at the facility. Allegation : Resident sustained unexplained injury while in care On 08/21/2024, staff observed that R1 had a small bruise on the left lower outer eye area around 12:00 PM. LPA interviewed S1-S5 who confirmed that the Administrator, Resident Care Coordinator, and Primary Care Physician were notified the same day. A skin check was conducted, and no other injuries were found. The resident, who is bedridden and has Alzheimer’s, denied pain, and staff reported no signs of distress. ***CONTINUE ON PAGE 9099C*** Unsubstantiated ***CONTINUE FROM 9099*** The facility reviewed video surveillance showing only staff entered R1’s room during the time frame of 6:30 AM to 12:00 PM. The internal investigation concluded the injury may have been caused by either R1's long fingernails or accidental contact with hospital bed rails during repositioning. A corresponding Unusual Incident Report for the injury was submitted to CCL. LPA interviewed W1 who stated that when she visited R1 on 08/24/2024 and observed what appeared to be a full black eye, not a minor bruise. W1 took photographs and contacted facility staff, but no additional explanation was provided at that time. W1 also contacted Kaiser, which led to a welfare check by the Alameda County Sheriff’s Office on 08/24/2024. It was reported that the officer interviewed R1 and staff but did not report any findings. W1 stated in written communication that no incident report was initially shared with them and that the description of the injury appeared inconsistent with what they observed in person. Allegation : Facility staff did not seek medical attention for resident in care LPA interviewed S1-S5 who confirmed that the resident’s physician was notified the same day via faxed. There is no indication in the facility's records that an in-person physician visit was ordered or conducted. Facility records indicate that the resident was assessed for additional injuries, found to be stable, and showed no signs of pain or discomfort. The resident’s care plan was reassessed, and follow-up action was taken, including changes to repositioning protocol and equipment. LPA interviewed W1 who reported that after observing the injury on 08/24/2024, they contacted Kaiser to request medical evaluation for R1 but W1 did not want R1 to go to Kaiser. W1 worried that if R1 went to the hospital she would be exposed to Covid. Kaiser requested Alameda County Sheriff’s Department to perform a welfare check. Documentation submitted by W1 includes photographs of R1’s injury and email communications expressing concern that no physical medical evaluation had occurred and that no clear explanation of the injury was available. Interviews with facility staff revealed that R1 received proper medical evaluation for her injury. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** This agency has investigated the above allegations. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, May 16, 2025 · control 15-AS-20240826155302

Type of visit: Required - 1 Year

On 08/01/2024 at 9:40 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Elizabeth Carson and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ rooms, bathrooms, two activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 111.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/20/2024. Emergency Disaster Plan was last posted on 01/12/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/13/2024. At 11:34 AM, LPA reviewed 5 staff records and all were complete. At 12:30 PM, LPA reviewed 6 residents records, and all were complete. at 1 PM, LPA reviewed 6 residents medications. LPA also reviewed and obtained a copy of the following documents: LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance Current Administrator’s Certificate renewal documents. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 1, 2024

Type of visit: Case Management - Incident

On 2/15/2024 at 1:50 PM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit to clarify/ gather information upon an incident report that LPA received on 2/06/24. LPA met with Administrator, Elizabeth Carson and explained the purpose of the visit. LPA reviewed and obtained R1 after visit summary. LPA interviewed S1 regrading of the incident that led to R1 hospitalization. LPA reviewed R1 MAR. S1 stated R1 develop a cough on 2/2/24 doctor prescribed PRN. Staff was instructed to give med to R1 as prescribed by R1 doctor. On the day of 2/6/24 R1 daughter came to visit R1 was doing well. Around 7PM R1 was reported by a staff member that R1 wasn’t doing well. R1 daughter was notified and R1 sent out to the hospital. R1 had returned to the community with new med changes as well as diet change. R1 is now on home health. S1 spoke to R1 daughter and R1 daughter do not have any question regrading R1 condition. No deficiencies issued during the visit and a copy of this report is provided via email.the state’s words, verbatim · CDSS document, Feb 15, 2024