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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 11/08/2023
Date Signed: 11/08/2023 02:08:39 PM


Document Has Been Signed on 11/08/2023 02:08 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: 64DATE:
11/08/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Lacy BerryTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Cassie Yang 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 met with Lacy Berry, Administrator, and explained the purpose of the visit.

During today's visit, LPA was provided the Compliance Binder, and observed a copy of the Stipulation in the binder. LPA observed Care Plan Reviews to last be conducted on 10/12/2023. LPA observed recent quarterly training to be conducted on 8/22 Fall Reduction, 9/26 Changes in Condition, 10/18 Dementia Care, along with printouts of PowerPoint presentation.

LPA observed documentation of the last quarterly visit conducted by Solar Senior Living representative, Jonathan Harris, to be on August 8, 2023. LPA informed Administrator LPA will discuss with Licensing Program Managers if quarterly visits with Solar Senior Living and Ciminocare are to be conducted in tangent, as LPA observed the current quarterly visit to be offsetting. LPA obtained a copy of Solar Senior Living and Ciminocare Quarterly Visits log, and statements from 07/27/2022 to 08/08/2023.

LPA observed no quarterly audit has been conducted by Allen Flores Consulting Group since LPA's last quarterly visit conducted on 8/23/2023 as the most recent audit was completed on 8/17/2023.

LPA is requesting a copy of facility's LIC 309 ADMINISTRATIVE ORGANIZATION. Additionally, LPA is requesting a copy of the most recent quarterly audit conducted by Allen Flores Consulting Group on 8/17/2023. All documents are to be submitted to LPA by close of business 11/15/2023. If by 11/15/2023, no new audit has been completed by Allen Flores Consulting Group, LPA is requesting a copy of the new audit once available.

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: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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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