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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 08/14/2024
Date Signed: 08/14/2024 02:37:06 PM


Document Has Been Signed on 08/14/2024 02:37 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:LOPEZ, ALLISONFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 63DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator, Allison LopezTIME COMPLETED:
02:00 PM
NARRATIVE
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On 8/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required 1-year annual inspection utilizing the CARE tool. LPA met with Administrator, Allison Lopez, and explained the purpose of the visit.

Facility's census is 63, with two (2) residents on hospice services. Facility is licensed for 110 non-ambulatory, hospice waiver of 8.

LPA and Administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. During today's tour, LPA observed eight (8) residents rooms, activity room, living room, shower room, dining room, bathrooms, beauty shop, med room and the common areas. LPA observed fire extinguisher to be serviced on 1/15/2024. LPA observed residents eating lunch in the dining room. During time of visit, LPA was unable to inspect kitchen as it was being occupied.

LPA observed the shower room flooring to have pink discoloration, what observed to be possible mildew, around the floor border. Additionally, LPA observed the air vent to be dusty. LPA advised facility to clean the filter to improve ventilation in the shower room. LPA took four photos of the following observation.

File review conducted of five (5) personnel records and seven (7) residents records.

CARE inspection tool completed and as a result of today's inspection, deficiencies was cited. Please see LIC 809-D.

Exit interview conducted, and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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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Document Has Been Signed on 08/14/2024 02:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed the shower room to have pink mildew around the floors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee is to conduct a plan of how facility will ensure shower room floor remains clean and sanitary.
Plan is to be implemented and submitted via fax/email to LPA by due date of 8/30/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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