<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592101
Report Date: 02/21/2023
Date Signed: 02/21/2023 03:07:24 PM


Document Has Been Signed on 02/21/2023 03:07 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
GREATER LA AC/SC, 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:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 AM
MET WITH:Rabena, R & JTIME COMPLETED:
03:16 PM
NARRATIVE
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
Licensing Program Analyst (LPA) Alberto Lopez conducted an annual required visit. LPA met with Licensee 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 5 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. 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 and sprinkler system installed.

The hot water temperature measured between 116.9– 118.7 degrees F. Drano solution was unlocked in bathroom #1 accessible to residents. Some PRN medications lacked labels and PRN letters.

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.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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 02/21/2023 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(1)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 2 persons , R2 did not have PRN letter for Seroquel, and R5 did not have PRN letter for Bisacody which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2023
Plan of Correction
1
2
3
4
Administrator will obtain PRN letters for the above and send proof to LPA by POC date. Alos, Administrator will porvide inservice to staff on proper administration of PRN.
Incidental Medical and Dental Care Services

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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/21/2023 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having (1) Drano container unlocked in bathroom #1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
1
2
3
4
Cabinet was locked during visit, ****no further actions is required****
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3