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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 10/14/2021
Date Signed: 10/14/2021 05:10:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:LACY BERRYFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 59DATE:
10/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Stephanie Paz, Resident Care Coordinator TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met with Karlisha, Med-Tech, initially, and explained purpose of inspection was to randomly speak to residents about living at the facility. Administrator was not present at the facility at the time of LPA's arrival. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

LPA began the inspection in the resident dining room and observed several residents to be finishing from eating lunch. LPA spoke to several residents who were in the dining room and then to additional residents who were awake in their rooms with the door open. LPA spoke to approximately (15) residents. LPA spoke briefly to Stephanie Paz, Resident Care Coordinator, who had to leave the facility during the inspection.

There are no deficiencies being issued on this report.

Exit interview with Med-Tech/Lead. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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