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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 03:50:38 PM


Document Has Been Signed on 02/22/2024 03:50 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 - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Vicky Cross, Lacy Berry, Allison LopezTIME COMPLETED:
03:55 PM
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On 2/22/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with Administrator, Vicky Cross, and Regional Nurse, Allison Lopez, explained the purpose of the visit.

LPA discussed the incident that occurred with R1 and R2. LPA learned that on Monday February 19, 2024, R1 was upset and had pushed a chair, hitting R2's hand. Regional Nurse reported that R2 has a minor bruising but no other complaints. It was discussed that R1 was upset as he was asked to move out of another resident's seat.

R2 informed LPA that since the occurrence of this incident, R1 has not sat at R2's table as R2 disagreed with R1's behavior. LPA was informed R1 apologized for the incident and has not had any reoccurrence.

Administrator reported there is no concern separating R1 and R2. Administrator reported no other concerns at the facility.

No deficiencies cited.

Exit interview conducted. A copy of this report was emailed to the Administrator.
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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