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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601827
Report Date: 07/05/2023
Date Signed: 07/05/2023 05:55:40 PM


Document Has Been Signed on 07/05/2023 05:55 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:WALNUT ACRES RESIDENTIAL CAREFACILITY NUMBER:
197601827
ADMINISTRATOR:SUSAN CALDWELLFACILITY TYPE:
740
ADDRESS:22907 OXNARD STREETTELEPHONE:
(818) 348-2210
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Susan CaldwellTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility to conduct a required annual visit. The LPA met with Facility Administrator Susan Caldwell at approximately 9:40 a.m. and explained the reason for the visit.

The LPA along with Administrator Caldwell toured the physical plant areas inside and outside at approximately 10:20 a.m., with Administrator Susan Caldwell., to ensure that there are no health and safety hazards.

BEDROOMS: There are (5) bedrooms designated for resident use. Bedroom #1 is single occupancy with no private bathroom and an exit to the exterior. Bedroom #2 is single occupancy with no private bathroom and no exit to the exterior. Bedroom #3 is a shared room containing two beds, two closet spaces with outdoor access and a shared bathroom. Bedroom #4 is single occupancy with a private bathroom and a direct exit to the exterior. Bedroom #5 is single occupancy with a private bathroom and a direct exit to the exterior. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage.

BATHROOMS: Resident bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The bathrooms hot water measured between 108.5 degrees Fahrenheit and 117.0 degrees Fahrenheit.

KITCHEN: Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes,


utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees
Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable
food is adequate.
Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827
VISIT DATE: 07/05/2023
NARRATIVE
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There are no pesticides (poisons) or toxins stored in any food storage area or preparation
area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had
tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet. No flies or other vermin were observed.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social
distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. Medications were observed to be locked in a cabinet in the kitchen and contained at least 30 days of worth of medication. The laundry room is located in a backroom by the kitchen.

GARAGE: The LPA toured the detached garage which is used as the facility office. The garage was free of obstructions and the cabinets were properly secured at the time of the visit.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Furniture was observed to be in good repair. There were no bodies of water noted. The LPA observed a locked shed in the backyard which was inaccessible to residents at the time of the visit.



INFECTION CONTROL: During today’s visit, LPA Ascencio spoke with Administrator regarding the
facility’s infection control practices. There is 1 entry into the facility. Upon entry, the
facility has a central entry point for symptom screening. The LPA noted that the facility is allowing
visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal
Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The
facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation
room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of
COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

Continued on LIC 809 - C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827
VISIT DATE: 07/05/2023
NARRATIVE
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The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties:

- Starting at 11:35 a.m., during kitchen tour, LPA observed bleach in an unlocked kitchen cabinet under the sink accessible to residents. Staff secured items during tour.
- Starting at 12:15 p.m., during staff file review, LPA observed Staff #1 (S1) not associated to facility. LPA spoke to Administrator and stated they should have been associated. LPA check on Guardian and did not observe S1 associated to the facility. Administrator submitted documentation to CCL. An immediate $500.00 civil penalty was assessed.
- Starting at 12:20 p.m., during staff file review, LPA observed two (2) staff members not having their initial 40-hours of required training.
- Starting at 3:02 p.m., during resident file review, LPA observed Resident #1 (R1) not have a current LIC 602 Physician's Report for 2023. Additionally, 6 out of 6 residents did not have a signed Appraisal/Needs and Service Plan signed by the representative.

Due to time restrain, the LPA will continue the required annual at a later time.

Exit interview conducted and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 07/05/2023 05:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as bleach was observed under kitchen sink accessible to resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Staff secured item during visit. Administrator will conduct staff training on section 87309(a) and sent to CCL by 07/07/2023.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Staff #1 had their fingerprints but was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Administrator submitted documentations to CCL Regional Office for processing. Administrator will submit to LPA proof of staff member association to facility by 07/07/2023.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 07/05/2023 05:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as all staff members did not have their initial 40 hours of training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Administrator will submit a plan to have all caregiver trained in 40 hours of required training. Additionally, plan will include the process of training for new caregivers hired and trained. Administrator will submit plan to CCL by 07/14/2023.

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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 07/05/2023 05:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 out of 6 residents did not have their LIC 602 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Administrator will submit signed and completed LIC 602 to CCL by 07/14/2023.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 6 out of 6 residents did not have Appraisal/Need adn Service plan signed and dated by resident representative, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator will review Appraisal/Needs and Service with resident representative and submit to CCL by 07/21/2023.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 07/05/2023 05:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 out of 6 residents did not have a signed Admissions Agreement, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator will contact the resident's representative to signed and date the Admissions Agreement. Administrator will submit signed Admissions Agreement to CCL by 07/21/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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