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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003743
Report Date: 11/30/2023
Date Signed: 11/30/2023 01:19:52 PM


Document Has Been Signed on 11/30/2023 01:19 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:OLTEAN, MARIANAFACILITY TYPE:
740
ADDRESS:4120 WALNUT AVENUETELEPHONE:
(916) 718-6870
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Administrator- Mariana OlteanTIME COMPLETED:
01:25 PM
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On 11/30/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct an annual inspection utilizing the full CARE inspection tool. LPA met with Administrator, Mariana Oltean, and explained the purpose of the visit.

Facility census is six (6) residents in care, with three (3) residents on hospice services. During time of visit, LPA observed R1 to be leaving the facility with friends for lunch.

LPA and Administrator discussed the current concerns at the facility. Administrator stated no concerns with staffing. Administrator informed LPA there is concerns regarding family disputes with R2's family members. LPA informed Administrator LPA will seek advisory from management to better assist Administrator.

During today's inspection, LPA and Administrator conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured including but not limited to: kitchen, living room, laundry room, two (2) caregivers room, six (6) residents private rooms, two (2) shared restrooms and the common areas. LPA observed sharps, toxins and medications to be locked and secured. LPA observed facility to have ample supply of nonperishable foods. During LPA's tour of the facility, no immediate health, safety and personal rights violations was observed. No deficiencies observed.

LPA conducted a file review of four (4) residents records and four (4) personnel records. LPA observed residents and personnel files to be complete with the required documents. Full CARE inspection tool was completed and facility is found to be in compliance.

At this time, LPA is requesting a copy of facility liability insurance to be emailed to LPA by Friday 12/08/2023.

Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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