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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:35:07 PM


Document Has Been Signed on 05/24/2023 12:35 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: DATE:
05/24/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Representatives: Mark Cimino, Robert Godfrey, and Adina VarareanuTIME COMPLETED:
12:40 PM
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An office meeting was held on 05/24/2023 at 11:00 AM at the Sacramento North Regional Office on Goethe Road, Assistant Program Administrator (APA) Pam Gill, Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Lauren Crocker and Licensing Program Analyst (LPA) Cassie Yang met with Licensee and facility representatives: Mark Cimino, Robert Godfrey and Adina Varareanu, to discuss the compliance history of the facility. The purpose of the meeting is to ensure facility is in substantial compliance with regulations and to discussed the depending applications for CiminoCare.

Items discussed at the meeting included, but not limited to:
1. Additional Staff Training and Staffing
2. Compliance history
3. Content of stipulation in place
4. Current pending applications

The licensee agrees to the following by close of business day Friday June 2, 2023:
  1. The licensee agreed to train staff on proactive listening, social and emotional training
  2. The licensee will submit a plan of resident level of care assessment and how staff are competent
  3. The licensee will submit a plan of how Administrator is collecting resident concerns and responding concerns in practice and/or in writing.

CCLD agrees to the following:

1. Review the submitted plans and respond to CiminoCare within 72 hours.

As a result, no deficiencies cited. Exit interview conducted and a copy of report was provided to Licensee.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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