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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 04/18/2023
Date Signed: 05/12/2023 10:31:15 AM


Document Has Been Signed on 05/12/2023 10:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: DATE:
04/18/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lacy Berry and Robert GodfreyTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) CAssie Yang conducted a meeting via Microsoft Teams with Administrator, Lacy Berry, and CiminoCare Regional Director of Operations, Robert Godfrey, regarding the current concerns at the facility.

LPA and facility representatives discussed the following:
- resident council meeting
- food/menu concerns
- staffing concerns
- resident on resident aggression
- staff response time
- current count of pending/open complaints

At this time, LPA requested a copy of April 2023 menu and R1's call log as it was previously requested. LPA will submit a referral to technical support program for assistance with facility on high complaints.

Exit interview conducted, a copy of the report will be emailed to Administrator for signature.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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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