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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204701
Report Date: 10/27/2021
Date Signed: 11/02/2021 08:50:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BROOKDALE WALNUTFACILITY NUMBER:
198204701
ADMINISTRATOR:MATSUMOTO, CHRISTINAFACILITY TYPE:
740
ADDRESS:19850 E COLIMA RDTELEPHONE:
(909) 595-5030
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY:120CENSUS: 60DATE:
10/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Christina Matsumoto, administratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicole Spencer initiated a case management visit due to observed deficiencies during a visit on 10/27/21. LPA Spencer met with administrator Christina Matsumoto and explained the purpose of today's visit.

The following deficiencies were observed during the visit:
  • Linen requirements: Eleven beds did not have mattress pads/protectors.
  • Hot Water Temperature: Hot water was tested in all resident bathrooms; water temperature measured was not within normal limits of 105-120 degrees Fahrenheit. Rooms 101-110 and rooms 201-214 water temperature measured between 94.5-104.7 degrees Fahrenheit.
  • Maintenance and Operation - Toilets: The toilets in rooms 107 and 249 were in disrepair.
  • Furnishings Requirements: Required furniture for each room includes a chair, light/lamp, night stand, dresser, and closet. Room 109 was missing a night stand and room 251 was missing a dresser.
  • Signal systems: The emergency pull cord (signal system) was not in use and/or in disrepair in room 106 and in all memory care units.


Pursuant to Title 22, Division 6, Chapter 8, deficiencies were cited on the attached 809D pages. An exit interview was conducted with the administrator and a copy of this report and appeal rights was provided via email for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE WALNUT
FACILITY NUMBER: 198204701
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2021
Section Cited

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87303(e)(2) Maintenance and Operation: 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 was not met as evidenced by...
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Based on observation, the licensee did not ensure that hot water temperatures were above the required 105 degrees F in rooms 101-110 and 201-214. This poses an immediate risk to the safety of persons in care.
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Type B
11/01/2021
Section Cited

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87303(e)(6) Maintenance and Operation: Toilet, handwashing and bathing facilities shall be maintained in operating condition. This requirement was not met as evidenced by...
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Based on observation, the licensee did not ensure that toilets were in operating condition in 2 out of 89 rooms (rooms 107 and 249). This presents a potential risk to the health, safety, and personal rights risk to persons in care.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE WALNUT
FACILITY NUMBER: 198204701
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2021
Section Cited

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87303(i)(1)(A) Maintenance and Operation: 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: (A) Operate from each resident's living unit. This requirement was not met as evidenced by...
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Based on observation and interview, the licensee did not ensure that the signal systems were operating in room 106 and in memory care units. This poses a potential risk to persons in care.
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Type B
11/01/2021
Section Cited

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87307(a)(3)(B) Personal Accomodations and Services: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement was not met as evidenced by...
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Based on observation, the licensee did not ensure that each bedroom had the required furniture in rooms 109 and 251. This poses a potential personal rights risk to persons in care.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE WALNUT
FACILITY NUMBER: 198204701
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2021
Section Cited

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87307(a)(3)(C) Personal Accomodations and Services: Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. This requirement was not met as evidenced by...
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Based on observation, this requirement was not met as evidenced by eleven resident rooms were missing mattress pads/protectors. This poses a potential risk to the health, safety, and personal rights of persons in care.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4