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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 08/23/2023
Date Signed: 08/23/2023 01:15:32 PM


Document Has Been Signed on 08/23/2023 01:15 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 61DATE:
08/23/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lacy BerryTIME COMPLETED:
01:30 PM
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On 8/23/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to conduct an unannounced quarterly on-site visit regarding the Stipulation and Waiver and Order adopted on 05/23/2022. LPA and LPM met with Lacy Berry, Administrator, and explained the purpose of the visit.

LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder and at a conspicuous space by the front desk.

During today's inspection, LPA observed two (2) missed weekly calls, week of 06/19/2023 and 06/26/2023, with Alan Flores Consulting Group, due to vacation from 6/21/2023-6/29/2023. LPA and Administrator discussed rescheduling the required calls to fulfill the condition of the Stipulation.

LPA observed monthly staff needs review to last be conducted on 8/4/2023 with notation of hiring more caregiver and housekeepers. Administrator informed LPA there are no staffing concerns but would like to be overstaffed. LPA observed the recent quarterly clinical audit was conducted on 8/17/2023.

LPA and Administrator discussed the details of documentation for End of Shift Report, and charting notes.

As a result of today's visit, no deficiencies cited.

Exit interview conducted. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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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