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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:17:02 PM


Document Has Been Signed on 12/06/2023 12:17 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: DATE:
12/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Allison Lopez and Lacy BerryTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the incident reports LPA received on 11/28/2023 and the SOC 341 received on 12/1/2023. LPA met with Administrator, Lacy Berry, and explained the purpose of the visit.

During today's visit, LPA and Administrator discussed the incident report for R1 and R2 received on 11/28/2023 regarding bed bugs. LPA was informed exterminator arrived to the facility and conducted a "fire" treatment immediately upon discovery. When asked if Administrator is able to identify the source, Administrator stated "no it was random". Administrator reported R1 and R2 has returned to their rooms. Administrator informed LPA facility is conducting a weekly checks when residents are having lunch as a preventative.

Additionally, LPA and Administrator discussed the SOC 341 received by email on 12/1/2023. LPA was informed facility was aware of this incident after Thanksgiving when R3 returned to the facility. LPA was then informed by Allison Lopez, SOC 341 was originally faxed in to CCLD on 11/28/2023. It was further discussed R3 and R4 has been separated in the dining room since acknowledgement of incident. Additionally, facility has designated a caregiver to supervise R4 with 1-on-1 care.

LPA and Administrator discussed the change of condition for R4. Administrator stated R4 has been observed in the past to be packing belongings and wanting to leave the facility. LPA was informed a care conference has been attempted by the facility to discuss R4's higher level of need. Administrator informed LPA she will continue to attempt conference with R4's responsible parties and if failed, facility will discuss the next steps with LPA and Long Term Care Ombudsman.

LPA attempted contact with R3 but there was no response at the door. LPA was able to contact with R4 who was having 1-on-1 care. As a result of today's visit, no deficiencies observed.

Exit interview 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: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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