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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 09/07/2023
Date Signed: 09/07/2023 11:26:22 AM


Document Has Been Signed on 09/07/2023 11:26 AM - 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: 63DATE:
09/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lacy BerryTIME COMPLETED:
09:30 AM
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On 9/7/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding the deficiencies LPA cited the facility on August 24, 2023 for complaint Control Number 25-AS-20220926150347 and Control Number 25-AS-20230120114145. LPA met with Administrator, Lacy Berry, and explained the purpose of the visit.

LPA explained to Administrator that failure to correct plan of correction by the given due date could and will result to $100 per day until corrected civil penalty. LPA additionally informed Administrator that POC may be extended if requested by Licensee.

Administrator informed LPA she was off for a few days and had forgotten to submit POC to LPA prior to leave.

During today's visit, LPA cleared the following POC as LPA received the POC via email the day prior to visit at 7:34PM:
  • CCR 87465(a)(4) 87465 Incidental Medical and Dental Care
  • CCR 87468.1(a)(1) 87468.1 Personal Rights of Residents in All Facilities

As a result of today's inspection, civil penalties were assessed.

Exit interview conducted and a copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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