198603444-12-16-2025-28-AS-BPEA-DPF2J9-20251216162559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603444
Report Date: 12/16/2025
Date Signed: 12/16/2025 04:26:30 PM

Document Has Been Signed on 12/16/2025 04:26 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	EVEREST AT WALNUT VALLEY SENIOR LIVING		FACILITY NUMBER:	198603444
ADMINISTRATOR/ DIRECTOR:	MATSUMOTO,CHRISTINA		FACILITY TYPE:	740
ADDRESS:	19850 COLIMA ROAD		TELEPHONE:	(909) 595-5030
CITY:	WALNUT	STATE: CA	ZIP CODE:	91801
CAPACITY: 120		CENSUS: 81	DATE:	12/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:17 AM
MET WITH:	Christina Matsumoto - Executive Director		TIME VISIT/ INSPECTION 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) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Christina Matsumoto, Executive Director and explained the purpose of the visit. The facility is licensed to serve for a capacity of (120) non ambulatory residents, age range 60 and over, of which (10) may be bedridden. Rooms 129-145 and all 1st floor rooms approved for bedridden except for room 101, 103, 105, 107, 109, and 111. Exterior gates approved for delayed egress. Hospice waiver for (20) has been approved. The facility has a new management, Walnut Silver Town effective 10/15/2025. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathrooms have hygiene items such as paper towel, hand soap and toilet paper. Staff are adhering to infection control requirements. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan. The facility has a dementia care plan to accept or retain residents with dementia. Facility maintains the required liability insurance which expires on 12/22/2025. Facility does not handle residents cash resources. Physical Plant/Environment Safety: The facility is a 2 story building with resident rooms on both floors. The main floor consists of the main lobby, administrative offices, activity room, dining room, kitchen, resident rooms, laundry room and the memory care unit. The 2nd floor consists mainly of resident rooms, medication room, office, laundry room and activity rooms. LPA selected random rooms in the 1st and 2nd floors to inspect. They are clean and have the required furnishings. There are no items obstructing the walkways. The fireplace is adequately screened. There are multiple carbon monoxide detectors in each hallway and fire sprinklers throughout the facility. There are shaded areas with outdoor furniture in the Memory Care unit and Assisted Living unit provided to the residents. There are no pools or large bodies of water. Facility has sufficient space to accommodate indoor and outdoor activities. There are planned activities daily. There are sufficient food supplies of 2-day perishable and a week of non-perishable items as well as water supply. The foods are properly stored in the refrigerator. There are no security bars or weapons on the premises. The facility has central air and heating accommodations. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Storage areas for cleaning solutions, toxic, knives, and hazardous items were inaccessible to residents. The fire extinguishers were observed to be fully charged. ***CONTINUED ON LIC809-C***

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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

FACILITY NAME: EVEREST AT WALNUT VALLEY SENIOR LIVING	FACILITY NUMBER: 198603444
	VISIT DATE: 12/16/2025

NARRATIVE

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Staffing: A total of 62 staff members including the Administrator provide care and supervision to the residents. There is sufficient staffing for each shift. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records-Training: The Administrator's certificate expires on 07/25/2027. Staff have criminal background clearance and training. (7) staff files were reviewed. There is at least one staff with CPR & First Aid training on each shift. Proof of staff training, health clearance and 1st Aid/CPR training are current.
Resident Rights-Information: A total of (10) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Needs/Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records, RCFE complaint poster and Personal rights were observed posted in the lobby.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the lobby and the elevator. The facility has a Resident Council.
Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed.
Incidental Medical and Dental: Residents medications were reviewed containing 30-day supply of medications to confirm medication is given as prescribed and is documented properly. The facility uses the Quick Medication Administration Record (MAR) log to document medications given. Medications are centrally stored and locked in the medication room. Facility uses medical carts. Medications are administered as prescribed. Medical and dental transportation is provided. First aid is available and stored in each medical cart.
Resident Records-Incident Reports: Resident files are kept in a secured 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.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers. Facility conducts fire drill at least quarterly for each shift. Last fire drill was conducted on 09/29/2025.
Residents with Special Health Needs: (2) residents who are utilizing oxygen tanks have signs posted at the front door. There are (10) residents receiving hospice care in the facility. Staff provide support care and supervision appropriate to meet the need of the residents receiving care from a Hospice agency.

No deficiencies cited. An exit interview was conducted, and a copy of this report was provided to Christina Matsumoto, Executive Director.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

LIC809 (FAS) - (06/04)

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