Willow Creek Alzheimer's & Dementia Care Center

On 09/14/2021 at 1:11pm, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Teresa Truong and explained the purpose of the visit. During the inspection, LPA toured facility including but not limited to common areas, bathrooms, dining room, kitchen and backyards. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed PPE, food and paper supplies are sufficient. COVID-19 screening questions were maintained at the facility for all staff, residents, and visitors at entry. Hand sanitizer is provided at facility entrance. Commonly touched surfaces are disinfected 2-3 times a day. During record review, LPA observed facility has a copy of Mitigation Plan on file. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

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.

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.

***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.

However, facility still refused to let her visit. Administrator confirmed with the Department that at that time the facility has not allowed any visitation since March 2020. Administrator stated on 8/21/2021 that she is aware of guidelines outlined in PIN 20-38 ASC issued in October 2020 in regard to end of life visitation. However, despite knowing the guidelines, Administrator states that she did not and will not allow end of life visitation. Therefore, the above allegation is substantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 Sec 87468.1(11) Personal Rights of Residents in All Facilities, is being cited on the attached LIC 9099D. Failure to correct deficiency by POC date may result in civil penalties. Exit interview conducted with Administrator; Appeal Rights was provided.

Statements from the interviews show that R1’s health was declining prior to being given the wrong medication and R1 did not show signs of a reaction to the medication and it is not believed that taking the wrong medication played a part in her death. The death certificate states cause of death was Alzheimer's disease. Based on all information obtained by the Department, the allegation is UNSUBSTANTIATED. An unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and copy of this report provided

On 11/09/2022 at 9:15AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Teresa Truong and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, courtyard, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. During record review, LPAs reviewed a sample of 5 staff records and observed 5 of 5 have health screening with TB test on file. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/01/2022: 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.