Willow Creek Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Caregiver, Pamela Flemming, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and two (2) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 114.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguisher and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and also reviewed two (2) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Care staff Pamela Flemming to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, kitchen, common areas and perimeter of care facility. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files, two (2) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of this visit, deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 23, 2025

Allegation investigated: Staff are not following resident's hospice care plan Staff did not feed resident in a timely manner

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA spoke to administrator Gabriela Lepadat over the phone and met with caregiver Pamela Flemming during today's inspection. LPA investigated allegation, “Staff are not following resident's hospice care plan.” During the course of investigation LPA conducted a file review and interviews with staff and witnesses. Relevant Party indicated caregivers were not following hospice care plan by not utilizing hospice equipment and not properly communicating with hospice. LPA interviewed caregivers in which they stated they always followed the hospice care plan. LPA interviewed the hospice nurse in which they stated they had no problems with the care staff, and they staff always listened to hospice instructions. Due to the information gathered, LPA finds allegation to be unfounded. LPA investigated the allegation, “Staff did not feed resident in a timely manner.” LPA conducted a file review and interviews with staff and witnesses. Relevant party indicated staff would not feed resident meals in a timely manner which led to him waiting for breakfast until the afternoon. Continuation on 9099-C. Unfounded LPA interviewed caregiver in which she stated resident would normally eat a large breakfast, sleep through lunch, and have a snack and then eat dinner. Depending on the day resident would sleep in and once awake they would offer breakfast. Caregivers had to assist with feeding resident due to resident limitations. LPA interviewed hospice nurse in which they stated there were not issues with staffing feeding resident properly. The nurse stated resident was sleeping more frequently so his mealtimes were frequently different then the normal meal hours. Due the information gathered LPA finds allegation to be UNFOUNDED. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of report provided. Relevant Party indicated that caregiver was rough with resident during care. LPA interviewed caregiver in which she stated she was never rough with resident during care. Caregiver stated resident had behaviors of aggression at times, but she was never rough with him. LPA interviewed administrator in which she stated she has never received any complaints or concerns about caregiver being rough and has never witnessed caregiver being rough with any residents. LPA interviewed hospice nurse in which he stated he never observed caregiver being rough or heard of any complaints about caregiver being rough. Hospice nurse stated that resident did have behaviors of aggression, but they were stabilized with the proper medications. Due to the conflicting information gathered, LPA finds allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff left resident in soiled briefs which resulted in an infection.” LPA conducted a file review and interviews with staff and witnesses. Relevant party indicated resident was left in urine soaked briefs which lead to resident having a fungal infection. LPA interviewed the caregiver in which she stated upon resident being admitted to the facility the staff and hospice groomed resident and cleaned him and found a fungal infection. Hospice nurse was aware and prescribed medications to clear the infection. Caregiver stated resident had behaviors of taking off clothing and briefs but caregivers always cleaned resident and made sure he was dry. LPA interviewed hospice nurse in which they stated caregivers were taking good care of resident and keeping resident clean properly. Nurse stated resident did have a fungal infection they were treating but did not know the cause of the infection. Hospice nurse stated he had no concerns with the care being provided. Due to the information gathered LPA finds the allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff shaved a resident in care without permission.” LPA conducted a file review and interviews with staff and witnesses. Relevant party indicated that caregiver shaved resident’s eyebrows and mustache off without anyone’s consent. LPA interviewed caregiver in which she stated when resident was admitted into the facility, he was disheveled and needed to be groomed. Caregiver and hospice helped shave and groom him, but they did not shave off his eyebrows. LPA interviewed the hospice nurse in which he stated grooming and shaving resident was on resident hospice care plan. Hospice nurse stated he could not recall if resident’s eyebrows were shaved. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED. Continuation on 9099-C. LPA investigated allegation, “Facility violated resident’s personal rights.” LPA conducted a file review and interviews with staff and witnesses. Relevant party indicated resident was denied phone calls and visitors at the facility. In addition, Relevant party indicated facility was denying resident his mail. LPA interviewed administrator in which she stated resident was never denied visitors, mail, or phone calls. Administrator stated she picks up the facility mail and resident did not receive much mail. LPA interviewed caregiver in which she stated she did not deny resident visitors, calls, or mail. Caregiver stated resident slept a lot during the day so sometimes someone would call the facility phone and the caregiver would report that resident was sleeping and to call back later. Caregiver stated she’d always relay messages to the resident once resident woke up. LPA interviewed the hospice nurse in which he stated he didn’t witness caregivers denying resident phone calls or visitors. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Exit interview was conducted and copy of report provided.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 59-AS-20240905012108

Type of visit: POC

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a POC visit. LPA spoke to administrator Gabriela Lepadat over the phone and met with caregiver Pamela Flemming during today's inspection. LPA toured the facility and inspected resident rooms and common areas. LPA observed all deficiencies cited on 8/08/24 have been cleared. POC letter and a copy of report was provided. Exit interview conducted.the state’s words, verbatim · CDSS document, Sep 11, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with care staff Pamela Flemming during today's inspection. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 5 resident rooms, 1 staff room, 2 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 3 of 5 resident files and 2 staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed the facility did not have an infection control plan and R1 had a full bedrail and is not on hospice care. Administrator to send into LPA a copy of current liability insurance. Deficiencies cited on 809-D. Appeal rights provided. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 8, 2024