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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003743
Report Date: 11/26/2024
Date Signed: 11/26/2024 02:49:57 PM

Document Has Been Signed on 11/26/2024 02:49 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 HOME CAREFACILITY NUMBER:
347003743
ADMINISTRATOR/
DIRECTOR:		OLTEAN, MARIANAFACILITY TYPE:
740
ADDRESS:4120 WALNUT AVENUETELEPHONE:
(916) 718-6870
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Mariana OlteanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 11/26/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual visit utilizing the full care tool. LPA met with Administrator and explained the purpose of the visit.

Facility census is six residents in care with one on hospice services. Facility is licensed for six non-ambulatory and hospice waiver for four. LPA observed the presence of R1's hospice binder with communication and care notes, compliance to PIN 22-24 ASC.

During today's visit, LPA and Administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six residents bedrooms, two bathrooms, laundry room, kitchen and the common areas. LPA observed facility to have ample supply of clean linens. LPA observed facility to have 2+ days of perishable and 7+ days on nonperishable foods. Sharps, toxins and medications observed to be locked.

LPA observed fire extinguisher to be recently serviced on June 19, 2024. Emergency drills were conducted quarterly in January 2024, April 2024, July 2024, and October 2024. Emergency Disaster Plan observed to be reviewed and approved on May 1, 2024. Liability insurance observed to be active and in compliance to Health and Safety Code.

LPA observed Administrator Certificate to be active on Community Care Licensing Division website, expiration date of 02/24/2024 to 02/23/2026.

File review conducted for six resident records and three personnel records.

As a result of today's inspection, no deficiencies cited. Exit interview conducted and a copy of the report was provided.
Anthony PerezTELEPHONE: (323) 485-4915
Cassie YangTELEPHONE: (916) 201-1928
DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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