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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592101
Report Date: 08/17/2021
Date Signed: 08/18/2021 01:48:17 PM

Document Has Been Signed on 08/18/2021 01:48 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WALNUT HOME CAREFACILITY NUMBER:
191592101
ADMINISTRATOR:RABENA, R. & J.FACILITY TYPE:
740
ADDRESS:654 BONNIE CLAIRE DRIVETELEPHONE:
(626) 964-5215
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 6CENSUS: 5DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Josefina and Richardo Rabena, Licensee'sTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Linda Almaraz conducted an annual required visit. LPA met with Licensee's Josefina and Richard Rabena and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and is approved.

LPA inspected all bedrooms, bathrooms, dining and living room. Facility has a main entry point for screening. Each bedroom has a chair, bed, linen, dresser, light, sufficient closet space and required furniture and equipment. All bathrooms were toured and the toilets, hand washing and showers are safe and sanitary. The food in the kitchen has sufficient supply of 2 days perishable and 7 days non-perishable. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The backyard has a shaded area and sitting area. Medications are centrally stored, locked along with the records. Resident Medication logs and medication were reviewed along with emergency contact information. Staff training records for COVID-19 were reviewed. Smoke alarm and Carbon monoxide detectors were inspected and seem to be operational. The facility has (3) fire extinguisher that are within the required operable range.

The hot water temperature in bathroom #2 measured between 122.3 degrees F. A Lysol cleaner, Bathroom cleaner and Drano solution was unlocked in bathroom #1 accessible to residents.

Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted with the Licensee's and a hardcopy was provided. Appeal Rights was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/18/2021 01:48 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 08/17/2021 at 03:52 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WALNUT HOME CARE
FACILITY NUMBER: 191592101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: LPA and Licensee Richard checked water temperature for bathroom #2 and had a reading of 122.3 degrees F.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 2 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2021
Plan of Correction
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The licensee shall adjust water temperature for the whole facility to be within limits of 105-120 degree F and will monitor/log the readings for 7 days. Licensee will send monitoring log as proof of correction to LPA by POC due date
Type A
Section Cited
CCR
87309(a)(1)


This requirement is not met as evidenced by: LPA observed a Lysol cleaning solution, Bathroom foam cleaner, and a Drano solution in Bathroom #2, unlocked and accesible to residents. Per Richard, the Licensee the bottom of the cabinet is where they store the cleaning bathroom solutions but it is usually locked.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having (3) cleaning solutions unlocked in bathroom #1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2021
Plan of Correction
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Licensee shall ensure all cleaning solutions are locked and inaccessible to residents. Licensee locked solution during the visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
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