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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:43:34 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: 61DATE:
11/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lacy Berry, Administrator TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met with Lacy Berry, Administrator, and explained the purpose of today's inspection is to discuss an amended page to a complaint report previously issued on 12/30/2020.

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: surgical mask.

LPA and Administrator discussed the amended 9099-D page that is part of complaint findings for complaint 27-AS-20200515160116. Appeal rights were provided via e-mail following the inspection.

There are no deficiencies cited under this report.

Exit interview. Copy of report provided via e-mail following the inspection to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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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