197608197-10-20-2022-29-AS-SURA-CKDP85-20221020110457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608197
Report Date: 10/19/2022
Date Signed: 10/20/2022 11:05:24 AM

Document Has Been Signed on 10/20/2022 11:05 AM - 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 GARDENS		FACILITY NUMBER:	197608197
ADMINISTRATOR:	TAMARA BOODNERO		FACILITY TYPE:	740
ADDRESS:	5128 CEDROS AVENUE		TELEPHONE:	(818) 855-1459
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	6	CENSUS: 5	DATE:	10/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Maria Luisa Pante		TIME COMPLETED:	03:40 PM

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On 10/18/2022, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. This visit had an emphasis on infection control. LPA Urena arrived at the facility at 1:33 p.m. The LPA was greeted by staff Maria Luisa Pante. Staff contacted the administrator via phone, but administrator was unavailable. The LPA explained the reason of the visit.

Infection Control: Upon entry, the facility has a sign in book, and sanitizing gel. Infection Control signage was visible at entrance. Temperature was taken by caregiver, before allowing LPA Urena enter the premises. Temperature was recorded in sign in sheet.

From 1:48 p.m. to 2:30 p.m., LPA Urena and staff conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a one-story dwelling located in the back of the property.

Common Areas: These included the living room and dining areas. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The laundry area is locked in a laundry room off the hallway, detergents and cleaning supplies are locked in the laundry area.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Cleaning supplies and detergents are stored in a locked cabinet in the kitchen.

Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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 GARDENS	FACILITY NUMBER: 197608197
	VISIT DATE: 10/19/2022

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Bedrooms: Facility has six bedrooms designated for residents' use. All bedrooms were properly furnished and had sufficient lighting. There was appropriate bedding and linens. There is a staff room that is kept locked when not in use.

Bathrooms: Facility has six resident restrooms and one staff/visitor’s bathroom. Bathrooms were clean, shower areas were in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use, shaded areas were provided for residents and visitors. The outdoor area was free of hazards.

Garage Area: An adequate supply of emergency food and water supply for six residents and two staff was observed. Diapers, and Personal Protection Equipment (PPE) is adequate, and the facility is able to obtain additional supplies as needed.

The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued at this time. Exit interview was conducted, and a copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

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