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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003743
Report Date: 11/29/2022
Date Signed: 11/29/2022 01:37:11 PM


Document Has Been Signed on 11/29/2022 01:37 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:WALNUT HOME CAREFACILITY NUMBER:
347003743
ADMINISTRATOR:OLTEAN, MARIANAFACILITY TYPE:
740
ADDRESS:4120 WALNUT AVENUETELEPHONE:
(916) 718-6870
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Dacia FletcherTIME COMPLETED:
02:00 PM
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On 11/29/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Required- 1 Year annual inspection utilizing the infection control domain. LPA met with Caregiver, Dacia Fletcher, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and caregiver toured the interior and exterior of the facility including bathroom, (6) resident bedrooms, (2) caregiver room, laundry room, kitchen, backyard and common areas. In the areas toured, no immediate health, safety, and personal rights violation were observed. LPA observed the facility to have 2+ days of perishables and 7+ days of non-perishable foods. Fire extinguishers was observed to be last serviced on 10/14/2022. LPA observed the facility to have the Ombudsman and CCLD posters to be posted. LPA observed paper towels, soap and hand washing signs in bathroom. LPA observed sharps, toxics and medication to be locked and secured. LPA observed posted Administrator Certificate to be expired, Administrator informed LPA she never received the updated copy but it has been renewed. LPA confirmed via online website of CDSS Active Certificate List that Administrator Certificate #6024790740 has been renewed, expiration date of 02/23/2024. LPA completed the infection control domain and at this time the facility was found to be at substantial compliance.

LPA requested copy of LIC 500, LIC 308 and current Liability Insurance to be emailed to LPA Yang by Friday, December 9, 2022.

As a result of today's inspection, no deficiencies were observed.

Exit interview was conducted. A copy of report was left at facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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