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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 12/14/2021
Date Signed: 12/14/2021 01:30:50 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: 63DATE:
12/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lacy BerryTIME COMPLETED:
01:45 PM
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On 12/14/21, Licensing Program Analysts (LPAs) Kevin Mknelly and Cassie Yang met with Director/ Administrator, Lacy Berry. LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPAs are aware of a recent Covid Positive staff and one round of response testing completed with all results negative. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Masks. Additionally, LPA was screened by staff, upon entering the facility.

The purpose of this inspection was to conduct a records review to tabulate identified resident care needs.

LPAs conducted records reviews for residents R1- R12 and R13, 15 and 17.

LPA will send Administrator a follow-up email and provided Administrator with a list of questions regarding the records reviewed.

As a result of today’s inspection, no deficiencies were cited at this time.


LPA(s) will return to continue the records review.

LPA Mknelly reviewed this report with the Administrator and provided a copy.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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