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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000961
Report Date: 10/10/2022
Date Signed: 10/10/2022 12:08:39 PM


Document Has Been Signed on 10/10/2022 12:08 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: 182DATE:
10/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Debbie InfieldTIME COMPLETED:
12:25 PM
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On today’s date, Licensing Program Analyst (LPA) LPA Edward Tapia conducted a Case Management-Incident visit with the purpose to discuss a resident attempted suicide which occurred on 10/09/2022.

The facility is a three-level structure and licensed for 138 non-ambulatory with a hospice waiver for 20. This facility is a Residential Care For the Elderly Continuing Care.

During today’s visit, LPA Tapia toured the resident’s apartment. LPA interviewed staff and witnesses. LPA also reviewed and obtained copies of resident’s physician report, Admission Agreement and other pertinent documentation.

LPA will conduct another follow up visit at a later date. An exit interview was conducted with Administrator, and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
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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