198603444-10-27-2021-28-AS-LJNS-C87V6Q-20211027160954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603444
Report Date: 10/27/2021
Date Signed: 10/27/2021 04:11:01 PM

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:	WALNUT VALLEY SENIOR LIVING COMMUNITY		FACILITY NUMBER:	198603444
ADMINISTRATOR:	MATSUMOTO, CHRISTINIA		FACILITY TYPE:	740
ADDRESS:	19850 E. COLIMA ROAD		TELEPHONE:	(909) 595-5030
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY:	120	CENSUS: 60	DATE:	10/27/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Christina Matsumoto, administrator		TIME COMPLETED:	04:00 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 Analysts (LPAs) Nicole Spencer, Elizabeth Irra, and Nina Galarza conducted an announced pre-licensing inspection. LPA's met with administator Christina Matsumoto and explained the purpose of today's visit. An application was submitted to Community Care Licensing for a change in ownership request for a Residential Care Facility for the Elderly (RCFE) serving residents ages 60 and up. The requested capacity is for 120 non-ambulatory residents, of which 12 are bedridden. Structure: The facility is a two story building consisting of 89 resident rooms rooms/bathrooms, a kitchen, dining area, laundry rooms, a designated memory care unit, activity rooms, medications rooms and backyard area. Bedrooms: Each bedroom was inspected and had required furniture including chair, night stand, lamp, dresser, and closet. However, room 109 was missing a night stand and room 251 was missing a dresser. Bathrooms: Each bathroom has a working toilet, wash basin, bathtub/ shower, non-skid mats, and grab bars. Linens & Hygiene Supplies: Beds had the required linen/supplies which include: pillowcase, mattress protector, fitted sheet, flat sheet, blanket and comforter. However, eleven beds did not have mattress protectors. The administrator purchased more mattress protectors prior to the end of the visit. An adequate supply of extra linens were stored in the laundry room. Residents also have individual hygiene supplies including wash clothes, towels, toothbrush, toothpaste, body wash, lotion, comb and brush. Posters and Signage: Emergency Disaster Plan, Personal Rights, Labor Laws, and Complaint procedures were posted and readily available for review. Fire Extinguishers: Fully charged and serviced fire extinguishers were located throughout the facility. The facility has a working land line telephone. Food Service: Dishes, cups, flatware, and pots are stored in the kitchen, were inspected and in good repair. Knives and other sharp kitchen utensils were locked and inaccessible. There was an adequate supply of non-perishables (7 days) and perishable foods (2 days). A variety of foods were observed. *See LIC 809C for continuation.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WALNUT VALLEY SENIOR LIVING COMMUNITY	FACILITY NUMBER: 198603444
	VISIT DATE: 10/27/2021

NARRATIVE

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Smoke Detectors: Inter-connected smoke detectors were located throughout the facility and were tested and operational. The carbon monoxide detectors were observed and operational. Areas of Disrepair: The toilets in rooms 107 and 249 was in disrepair and the light bulb in room 218 needed to be replaced. Signal Systems: The emergency pull cord in room 106 and memory care unit rooms were not working. This was fixed prior to the end of the visit. Appliances: All appliances including stove, microwave, refrigerator, dishwasher and washer/dryer are in working condition. There are working refrigerators/freezers. The residence is equipped with central air and heating throughout the facility. Toxins: Cleaning supplies and toxins were locked and inaccessible. Residents with physician's report that allows them to have these items have them locked in their private room. Water Temperature: Hot water was tested in all bathrooms and the kitchen sink; water temperature measured was not within normal limits of 105-140 degrees Fahrenheit. Rooms 101-110 and rooms 201-214 water temperature was measured between 94.5-104.7 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated centrally stored medications were stored in a locked and labeled cabinet. The first-aid kit was inspected; it contained tweezers, thermometer, scissors, antiseptic, bandages, gauze, and First Aid Manual. Clients & Staff Files: Designated area for files were stored in locked areas. Fire Place: There was a fire place located in a common room area that was properly screened. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on August 10, 2021. Component III: Component III was conducted during this visit.

The following items must be corrected. Except for items that were corrected during the visit, proof of correction will be completed using a virtual video conference call on 11/1/21 at 3 p.m.

1. Ensure that all beds have mattress protectors (Fixed during visit)
2. Adjust water heater to within normal ranges of 105-120 degrees (Fixed during visit)
3. Ensure that signal systems for all rooms are operational (Fixed during visit)
4. Ensure that all occupied rooms have required furniture: Night stand for room 109 and dresser for room 251.
5. Areas of disrepair: rooms 107 and 249 toilet to be repaired; room 218 light bulb to be replaced.

An exit interview was conducted and a copy of this report has been furnished to the Administrator. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC809 (FAS) - (06/04)

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