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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 03:53:14 PM


Document Has Been Signed on 08/23/2023 03:53 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Lacy BerryTIME COMPLETED:
04:10 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 a Required 1- year annual inspection utilizing the CARE tool. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit.

Facility's census is 61, with two (2) residents on hospice services. Facility is licensed for 110 non-ambulatory, hospice waiver of 8.

During today's visit, LPA Yang observed facility is currently under renovation.

LPA Yang, LPM Munoz and Administrator observed (3) rooms to have a strong presence of urine smell from the hallway. LPM Munoz and Medical Technician reviewed the MAR and conducted medication counts for R1 and R2. LPA Yang took five (5) photos of medication, and obtained a copy of the MAR for R1 and R2. This observation is currently under review.

At 2:30 PM, LPA Yang and Maintenance Supervisor toured two (2) rooms together to conduct temperature check and observed the sink water temperature to be at highest, 95.4*. Maintenance Supervisor informed LPA since the rooms are at the end of the wing, it may not be as hot as the other resident rooms.

LPA was unable to complete the CARE tool during today's visit.

Exit interview conducted, and a copy of the report was provided.
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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