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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 08/24/2022
Date Signed: 08/24/2022 05:13:20 PM


Document Has Been Signed on 08/24/2022 05:13 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, 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: 64DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lacy Berry, Administrator and Veronica Sison, Resident Care Coordinator TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Lacy Berry, (Admin) and Veronica Sison, Resident Care Coordinator (RCC) and explained the purpose of the visit.

Prior to initiating the annual inspection, LPA 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by staff and answers were documented in their visitor screening log.

The facility is licensed for (110) non-ambulatory residents and has a hospice waiver for (8).Currently there are (64) residents and (4) residents receiving hospice services. LPA and RCC toured the interior and exterior of the facility including the common areas, activity room, medication room, shower room, kitchen, food storage area, laundry area, (1) employee bathroom and outdoor enclosed patio area with seating and shade. Multiple residents' rooms had doors open and were observed from the hallway. LPA observed all areas to be clean, in good repair and odor-free. LPA observed locked sharps in the kitchen, locked toxins in the laundry area, and locked medications in the medication room. LPA observed (5) residents participating in various activities in the activity room and activity calendar posted. LPA observed various Covid posters throughout the facility. Facility to post 20-second hand-washing posters at each kitchen/bathroom sink. All doors have exit alarms. LPA observed sufficient 2+ day perishable and 7+day non-perishable food, ice machine to be clean and various cleaning schedules posted in the kitchen. Fire extinguisher was last serviced 12/9/2021. LPA observed other required postings posted including Resident Rights and House Rules. LPA and Administrator discussed vaccination status of residents and staff and scheduling an upcoming booster clinic at the facility. PPE supplies sufficient.
cont on 809C..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
VISIT DATE: 08/24/2022
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809C(1). LPA observed the inside temperature to be 75*F. Administrator was provided with a current copy of staff roster printed and will update as needed.

LPA provided a box of sanitizers from the Regional Office supply during today's inspection.

LPA requested an updated copy of LIC500, LIC308 and of the current liability insurance be provided to the CCLD by 8/31/22.

There are no deficiencies issued during today's inspection.

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

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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