198603444-1-17-2023-28-AS-KLOG-CN6TV3-20230117140315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603444
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:03:51 PM

Document Has Been Signed on 01/17/2023 02:03 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, 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:	01/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Christina Matsumoto (Executive Director)		TIME COMPLETED:	02:15 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) Kruz Long conducted an unannounced visit to the facility to conduct an Annual Inspection. Upon arrival, LPA met with Christina Matsumoto (Executive Director) and explained the purpose of the visit. The facility is licensed to serve: AGE RANGE 60 AND OVER. 120 NON-AMBULATORY, OF WHICH 10 MAY BE BEDRIDDEN. ROOMS 129-145 AND ALL FIRST FLOOR ROOMS APPROVED FOR BEDRIDDEN EXCEPT FOR 101,103,105,107,109,111. 3 EXTERIOR GATES. APPROVED FOR DELAYED EGRESS. HOSPICE WAIVER FOR 10. During today's inspection, LPA observed the following: Facility maintains in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Facility is not operating over capacity or beyond any conditions and limitation on the license. No ammunition or firearms on the premises. Facility maintains a comfortable temperature for residents. All outdoor and indoor passageways are free of obstruction. Hot water temperature measured between 105 degrees F and 120 degrees F in various bathrooms on each floor. The presence of grab bars for each toilet, bathtub and shower used by residents was observed. Bathtub or shower have non-skid mats or strips. Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bed spreads. Adequate supply of linens are stored in supply room. Facilities have a signal system that operates from each resident’s living unit. Minimum of one week supply of nonperishable foods and 2 days of perishable foods was observed. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. Smoke and Carbon Monoxide detectors are operable. The facility has sufficient and competent staff to provide the services needed to meet resident needs. Delayed egress devices is not substituted for trained staff in sufficient numbers to meet the needs of all dementia residents and to escort residents who leave the facility. Items that could constitute a danger is stored inaccessible to dementia residents. Staff has criminal record clearance. Continue to LIC9099C.......

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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

FACILITY NAME: WALNUT VALLEY SENIOR LIVING COMMUNITY	FACILITY NUMBER: 198603444
	VISIT DATE: 01/17/2023

NARRATIVE

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Staff responsible for direct care and supervision have current first aid training. Facility have a disaster and mass casualty plan. Employee of CCLD is allowed to enter the facility to conduct inspection. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Centrally stored medications are kept safe and locked in the medication room..

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Christina Matsumoto,

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

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