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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603444
Report Date: 11/30/2023
Date Signed: 11/30/2023 01:10:15 PM


Document Has Been Signed on 11/30/2023 01:10 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 VALLEY SENIOR LIVING COMMUNITYFACILITY NUMBER:
198603444
ADMINISTRATOR:MATSUMOTO, CHRISTINIAFACILITY TYPE:
740
ADDRESS:19850 E COLIMA ROADTELEPHONE:
(909) 595-5030
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY:120CENSUS: 57DATE:
11/30/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Christina Matsumoto, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to finish the annual inspection. LPA met with Administrator, Christina Matsumoto, to explained the reason for the visit.

LPA continued the inspection using the CARE tools. The following domains were reviewed:
Staffing: The facility has sufficient staffing to meet the needs of the residents. There are awake staff providing night supervision in both assisted living side and the memory care unit.
Personnel Records-Training: LPA reviewed 5 Staff files. The administrator's (Christina Matsumoto) certificate expires on 7/25/25. Staff have fingerprint clearance and associated to the facility. Staff have appropriate dementia care training and ongoing training.
Resident Records-Incident Reports: LPA reviewed 5 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, and pre-appraisal form.
Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff.
Incidental Medical & Dental: The medications are centrally stored in the wellness office. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed 5 residents' medication and they are being administered as prescribed by the physician.
Residents with Special Health Needs: Facility accepts and retain residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. No smoking-Oxygen in use signs are posted where appropriate. The facility has approved delayed egress on 3 of the exterior gates.

No deficiencies are issued today. A technical violation is provided on the LIC9102 form. An exit interview was held and a copy of this report was given to Administrator Matsumoto.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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