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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 12/02/2021
Date Signed: 12/02/2021 01:07:56 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: 66DATE:
12/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lacy Berry, Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Sabrina Calzada and Kevin Mknelly and Long Term Care Ombudsman (LTCO) arrived unannounced to conduct a case management inspection to follow up on recent concerns brought to their attention.

LPA's and LTCO met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm if there are any positive Covid-19 diagnoses, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19. Additionally, LPA's were screened per Covid-19 precautionary measures upon entering the community. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 or surgical Mask.

During today's inspection, the following was discussed:
  • staffing levels and recruitment efforts
  • possible resident AWOL
  • timely receipt of new medication order and in getting medication filled
  • resident smoking area outside
  • technical support by the Department
  • technical support by the facility


The following documentation was requested to be provided by 12/8/21:
  • December staffing schedules (received 12/2/2021)
  • October/November 2021 staffing time cards
  • Personnel Report (LIC500)- current

There are no deficiencies cited in this report from today's inspection.

Exit interview with Administrator. Copy of report to be emailed to Administrator following the inspection.



SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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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