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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 05/15/2024
Date Signed: 05/16/2024 07:35:53 AM


Document Has Been Signed on 05/16/2024 07:35 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:VICKY CROSSFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 70DATE:
05/15/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mark Cimino and Vicky CrossTIME COMPLETED:
09:45 AM
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On 5/15/2024 at 9:00 AM, an office meeting was held with Sacramento North Regional Office via Microsoft Teams Meeting.

Present in the meeting was Licensee, Mark Cimino, Administrator, Vicky Cross, Facility representatives: Allison Lopez, Robert Godfrey, Adina Nitu, Payam Saljoughian, and Assisted Living Waiver Program Director Senior Care Solution agent, Lauren Firenze. Licensing representatives present: Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang.

Topics discussed during this meeting were:
  • R1's level of care and potential new placement
  • 30 Day Eviction Notice
  • Facility's plan of filing Notice to Vacate, if necessary


Exit interview and a copy of this report will be provided to the facility via email. A copy will be signed and returned to CCLD.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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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