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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 05/11/2023
Date Signed: 05/11/2023 05:49:29 PM


Document Has Been Signed on 05/11/2023 05:49 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
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: 62DATE:
05/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Lacy BerryTIME COMPLETED:
06:15 PM
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On 5/11/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. This is a joint visit with Long Term Care Ombudsman, Randy Dinning. LPA met with Administrator, Lacy Berry, and explained the purpose of the visit.

Today's visit, LPA was invited and attended the resident council meeting and observed the topics discussed:
-housekeeping
-food menu
-staffing

Additionally, LPA toured the interior of the facility to ensure the health and safety of residents in care. LPA interviewed five (5) residents. LPA provided a copy of the Regulation 87224 Eviction Procedure to Administrator.

No deficiencies cited.

Exit interview conducted and a copy of the report was left at the facility with Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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