197803700-8-26-2024-28-AS-THEA-D8HVE6-20240826162151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803700
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:22:06 PM

Document Has Been Signed on 08/26/2024 04:22 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 VILLA		FACILITY NUMBER:	197803700
ADMINISTRATOR:	MICKLE, VICKIE		FACILITY TYPE:	740
ADDRESS:	13975 TELEGRAPH RD.		TELEPHONE:	(562) 777-7200
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90604
CAPACITY:	20	CENSUS: 10	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Celina Vasquez - Administrator		TIME COMPLETED:	04:30 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) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Celina Vasquez - Administrator and explained the purpose for today’s visit. The facility is licensed to serve 20 Non-Ambulatory Residents, ages 60 and over. Facility may retain 10 hospice and 20 bedridden residents. There are currently 5 Residents using hospice services and 0 bedridden. The Facility is a single-story story building located in Whittier, CA. This is the unit that is in the rear of property. A tour of the facility included: 5 double-resident rooms with shared 1/2 bath, 2 semi-private rooms, 7 private rooms, 2 full bathrooms, living area, dining/activity area, kitchen, pantry, laundry room in detached unit along with storage, and patio area. Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Dementia Plan and training, and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, a total of 14 residents’ bedrooms were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems (or residents have pendants) which were tested and operating properly, however, alarm/buzzer on doors that lead to the exterior of facility were not operable (4 resident bedrooms have doors that lead to the exterior), details will be documented on 809-D. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested and was outside the required range of 105-120 degrees, measuring 132.3-137.8 degrees F, details documented in the 809-D. (Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WALNUT VILLA	FACILITY NUMBER: 197803700
	VISIT DATE: 08/26/2024

NARRATIVE

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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.
Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator Celina Vasquez certificate expires on 12/15/25.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 6 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted throughout the facility: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities and there is sufficient space both indoor and outdoor for activities.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. During todays visit LPA observed a medication error, details will be documented on 809-D.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 8/2024, drills are conducted monthly at facility..
Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be cited on the 809D.

Exit interview held, a copy of the report and appeal rights were provided to Celina Vasquez.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 04:22 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 VILLA	FACILITY NUMBER: 197803700
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465 Incidental Medical and Dental Care (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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation (during medication review), the licensee did not comply with the section cited above as LPA obsereved 2 medications missing 8/27/24 AM medication, LPA asked Administrator why medication was off on bubble pack (as administrator previously stated that each medication on particular residents medication reviewed was punched out daily on correct date number) Administrator was unsure why medication was off and could not provide explaination, nor were there any notes in MAR, this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	administrator will follow up with pharmacy so that all future refills have the correct amount of medication Licensee/Administrator to conduct an in-service training on proper medication administrator and provide LPA with training materials and training log with participants by 9/9/2024. this can be submitted via email to LPA tena.herrera@dss.ca.gov

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). 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 as LPA tested water temperature in Room #1 and in Resident full bath both temperatures were above 130 degress F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	during visit administrator lowered water temperature Licensee/Administrator to create a water log for the next 3 days and measure water temperature, water will be tested 3x a day (morning, day, evening) and all temperatures must be within the required range. Log must be emailed to LPA by 8/31/24. (log must begin 8/27-morning and end 8/30-evening). this log may be emailed to LPA tena.herrera@dss.ca.gov

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 04:22 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 VILLA	FACILITY NUMBER: 197803700
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 as during tour LPA observed a leak in the resident bathroom shower, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to have leak repaired and a copy of repair invoice is to be sent to LPA via email by POC due date. (tena.herrera@dss.ca.gov)

Type B

Section Cited

CCR

87303(i)(1)(B)

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. 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 aboveas during facility tour the buzzers on doors that lead to exterior of facility (4 which are resident rooms) LPA obsereved buzzers/ringers to not be working, this is a facility that has dementia residents, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	during visit Administrator purchased new signal/ring system for doors (total 8) that will be delivered to facility tomorrow 8/27/24 Licensee/Administrator to install new buzzers on all doors that exit the facility and submit a photo of new buzzers (installed) to LPA by POC due date. (tena.herrera@dss.ca.gov)

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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