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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881024
Report Date: 09/24/2021
Date Signed: 09/24/2021 12:59:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WALNUT SENIOR HOME IIFACILITY NUMBER:
361881024
ADMINISTRATOR:KAUR, GULVARGFACILITY TYPE:
740
ADDRESS:490 EAST WALNUT AVENUETELEPHONE:
(909) 714-2119
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:6CENSUS: 6DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Gulvarg KaurTIME COMPLETED:
01:15 PM
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On 9/24/21 Licensing Program Analyst (LPA) Shaunte Henry arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. A risk assessment was conducted via phone prior to arrival. LPA met with, Gulvarg Kaur, explained the nature of the inspection and was granted entry into the facility. LPA Henry was screened for COVID-19 symptoms. There are currently 6 residents at the facility. As of this date, there are no positive COVID-19 cases or individuals with COVID-like symptoms present in the facility.

LPA toured the facility. There is one point of entry for routine COVID-19 symptoms screening is initiated for all residents, staff and visitors. Signs have been posted throughout the facility which indicates the visitor policy and proper hand washing, cough/sneeze etiquette, and social distancing practices. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients. LPA observed hand sanitizer throughout the facility. All clients have at least a 30-day supply of medications. LPA observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPA observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, glasses, etc. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-like symptoms. The facility is aware that it is mandatory that CCL is contacted if anyone tests positive for COVID-19.

According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provided to Gulvarg Kaur.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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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