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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:15:31 PM


Document Has Been Signed on 02/22/2024 03:15 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:VICKY CROSSFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 72DATE:
02/22/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Vicky Cross, Lacy Berry, Allison LopezTIME COMPLETED:
02:45 PM
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On 2/22/2024, 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 Vicky Cross, 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 weekly calls conducted with consultant group to discuss medication room operation. LPA observed in-service education of Care Plan Review conducted on 2/1/2024 with shift manager and caregivers. LPA observed documentation of monthly staff training, Dementia training conducted on 1/17/2024 and Confidentiality/HIPPA training conducted on 2/20/2024.

LPA observed quarterly audit from consultant group last serviced on 11/13/2023. LPA was informed next audit is currently being conducted date of visit and the day after.

LPA observed documentation of Licensees quarterly on-site visits ensuring quality control conducted on 12/5/2023 by Solar Senior Living and on 12/9/2023 by Ciminocare.

At this time, LPA found facility to be in compliance with the Stipulations and Waiver; And Order. No deficiencies observed.

Exit interview conducted and a copy of report will be provided to Administrator via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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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