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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 08/24/2023
Date Signed: 08/24/2023 06:18:24 PM


Document Has Been Signed on 08/24/2023 06:18 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:
08/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lacy Berry and Robert GodfreyTIME COMPLETED:
06:30 PM
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On August 24, 2023 at 3:00 PM, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management annual continuation. LPA met with Regional Director, Robert Godfrey, and Administrator, Lacy Berry, and explained the purpose of the visit.

Regional Director informed LPA that Administrator is currently in a meeting with Long Term Care Ombudsman and other facility staff to discuss resident care plan. Licensing Program Manager (LPM) Laura Munoz arrived to the facility shortly afterwards.

During today's visit, LPA conducted resident interview and staff interviews. LPM conducted a resident and personnel file review and observed the files to be complete. LPM observed the fire extinguisher to be recently serviced. Additionally, LPM observed the facility to have 2+ days of perishable and 7+ days of nonperishable food present in the kitchen. Sharps and toxins were observed to be locked and secured. LPM observed call button to be missing in a resident's room. Administrator informed LPA that it was not notified to front desk and will provide a call light immediately to the room.

LPA, LPM, Administrator and Regional Director discussed the concerns at the facility, House Rules and process of providing 30-day eviction notices. Additionally, LPA and Administrator discussed concerns regarding medication and staffing. LPA and LPM was informed Alan Flores Consultant Group Nurse Consultant will provide an on-site to conduct a full medication audit for the facility.

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

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: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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