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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 05:14:37 PM


Document Has Been Signed on 08/24/2022 05:14 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lacy Berry, AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility to conduct an unannounced quarterly on-site visit pursuant to a Stipulation and Waiver and Order adopted on 5/23/22. LPA met with Lacy Berry, Admin, 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.

During today's inspection, LPA reviewed the "Compliance Binder" and observed it to be organized and to contain tab dividers for each requirement as set forth in in the Stipulation. LPA observed the weekly and monthly tasks to have been completed and up to date and quarterly staff training to have been conducted monthly from June -August 2022, and filed next to the specific training documentation. LPA observed a first quarterly audit was conducted on 6/3/2022 as well as an on-site visit on 7/26/2022. Administrator stated she has an upcoming training scheduled within the week. Semi-annual med-management training is not due until on/around November 2022.

LPA observed large binder with the most current care plan, reviewed/updated monthly, for each resident as well as a separate charting binder.

LPA observed Administrator place a copy of the Stipulation in the binder and re-post a copy at a conspicuous place at the facility.

There are no citations issued on this report.

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
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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