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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592101
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:14:51 PM


Document Has Been Signed on 11/30/2023 04:14 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: 6DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Richard Rabena, LicenseeTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA met with licensee, Richard Rabena, and explained the purpose of the visit. The facility is licensed for a capacity of 6 residents ages 60 and over, of which 5 may be non-ambulatory and one bedridden. Room #7 is approved for bedridden. Room #1 & 2 approved for staff and licensee. All the other rooms are for residents. There is a hospice waiver approved for 2 residents.

LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed:
Infection Control: The facility has submitted an Infection Control Plan. Staff are continuing to clean and disinfect the home. They are using appropriate hand hygiene and wearing gloves while assisting residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are no residents utilizing oxygen at this time.
Physical Plant & Environment Safety: The facility consists of 5 resident rooms, 2 Staff rooms, a living room, dining room, family room, kitchen, one common bathroom, and attached garage. There is a shared bathroom between rooms #6 and #7. Staff room #1 has a private bathroom. The backyard has a shaded area for resident use. The hot water temperature was measured between the required range of 105-120 degrees F. There are no swimming pool or bodies of water on the premises. The facility has a carbon monoxide detector located in the hallway near the kitchen.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency procedures are indicated on the form.
Due to time constraint, LPA will return another day to complete the remainder of the domains. There are no deficiencies observed during the visit today. An exit interview was held and a copy of this report was given to the licensee.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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