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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000961
Report Date: 06/08/2022
Date Signed: 06/08/2022 01:53:12 PM


Document Has Been Signed on 06/08/2022 01:53 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:WALNUT VILLAGEFACILITY NUMBER:
306000961
ADMINISTRATOR:NADINE A. ROISMANFACILITY TYPE:
741
ADDRESS:891 WALNUT STREETTELEPHONE:
(714) 776-7150
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:300CENSUS: DATE:
06/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Debbie Infield TIME COMPLETED:
02:00 PM
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On 06/08/2022, Licensing Program Analyst (LPA) LPA Edward Tapia conducted a Case Management-Incident visit with the purpose to discuss missing 14 karat gold filigree band.

This is a Residential Elderly Care for Continued Care facility.

Incident report states incident occurred on 05/31/2022. Resident states 14 karat gold filigree band appears to be missing. Resident states she cannot remember the exact date band went missing. Resident states she puts the ring away in her jewelry box or safe.

At 1:05 PM LPA Tapia interviewed Staff 1 (S1) and Staff 2 (S2). Staff (S1) states resident was in the apartment playing with their dog while housekeeper was cleaning. Resident was unable to provide an exact date ring went missing. (S1) interviewed Housekeeper and Maintenance Assistant and both stated they did not take the ring.

Q1: When did the resident report the ring missing? on 05/31/2022.

Q2: When did you contact the police? After ring could not be found.

Q3: What did you do when resident reported the ring missing? I interviewed the Housekeeper and Maintenance Assistant

Staff (S2) states they help resident look everywhere in their room but could not find the ring. A police report was filed on 06/01/2022 and Incident # T22003812 was provided. A copy of police report and LIC 9060 were provided to LPA.

Resident, Housekeeper and Maintenance Assistant were not available for interview.

LPA reviewed the theft loss policy and policy was followed regarding incident. LIC 621 Client/Resident Personnel Property Report was not provided as resident did not complete form.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WALNUT VILLAGE
FACILITY NUMBER: 306000961
VISIT DATE: 06/08/2022
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Based on today's observations and interviews, there are no citations being cited during today's visit. An exit interview was conducted with Executive Director Debbie Infield , and a copy of this report and LIC 811 were provided at exit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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