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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:07:26 PM


Document Has Been Signed on 07/24/2024 03:07 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: 65DATE:
07/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Allison LopezTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the current Administrator in place. LPA met with Facility Nurse/Interim Administrator and explained the purpose of the visit.

LPA was informed current Administrator on file, Vicky Cross, is no longer working at the facility. LPA was informed Facility Nurse is currently acting as Interim Administrator until Licensee finds an Administrator that is deemed fit for the facility. LPA was informed Facility Nurse/Interim Administrator does have an active Administrator Certificate.

LPA is requesting the required documents to be submitted to LPA via email to change Administrator on file until position is permanently fulfilled. Please provide the following below to LPA by Friday July 26, 2024 to remain compliance to CCR Title 22 Section 87405 Administrator - Qualifications and Duties.
  • Active Administrator Certificate and/or Proof of Administrator Certificate renewal
  • Document to confirm Facility Nurse has two years of college; at least three years experience providing residential care to the elderly; or equivalent education and experience as approved by the licensing agency.

At this time, no deficiencies cited.

Exit interview conducted and a copy of report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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