Willow Creek Alzheimer's & Dementia Care Center.

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.

***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*** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ***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.

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.

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.

On 9/29/23 at 9:25AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced required 1-year inspection and met with Rohini Chand resident coordinator. LPA explained reason for visit and toured the facility inside and out including but not limited to facility kitchen, hallway, activity area, dining room, bathrooms, outside area, and resident rooms. The hot water temperature in hallway bathroom measured at 111.4 degrees Fahrenheit and resident room #7 measured at 107.7 degrees Fahrenheit. The outside area is free of obstruction and bodies of water. Medications are centrally stored in a locked medication room that are only accessible by medication technicians. Facility freezer temperature was observed at 0 degrees Fahrenheit and refrigerator temperature was observed at 40 degrees Fahrenheit. Facility smoke and carbon monoxide detectors were observed as operational. The sprinkler system was last inspected on 7/27/23. Fire drill was last conducted on 7/2023. The fire extinguisher was last inspected on 3/2022. The first aid kit was observed to be complete. During record review, LPAs reviewed a sample of 5 staff records and observed 5 of 5 have health screening with TB test on file, and 5 residents have physician's report and care plans up to date. LPA reviewed 5 resident medications. LPA observed all resident medications were accurate with their doctor's orders. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.