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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 07:34:43 AM


Document Has Been Signed on 05/16/2024 07:34 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:
09:45 AM
MET WITH:Mark Cimino and Vicky CrossTIME COMPLETED:
10:30 AM
NARRATIVE
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On 5/15/2024 at 9:45 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, Licensing representatives: Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang.

The purpose of the meeting is to discuss the changes that were implemented in the facility since the office meeting last held on 1/31/2024.

Topics discussed during this meeting were:
  • Medication management
  • Staffing



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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