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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881024
Report Date: 10/14/2024
Date Signed: 10/14/2024 02:45:10 PM

Document Has Been Signed on 10/14/2024 02:45 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WALNUT SENIOR HOME IIFACILITY NUMBER:
361881024
ADMINISTRATOR/
DIRECTOR:		KAUR, GULVARGFACILITY TYPE:
740
ADDRESS:490 EAST WALNUT AVENUETELEPHONE:
(909) 714-2119
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:24 AM
MET WITH:Gulvarg Kaur-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPAs) LaVette Farlow and Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPAs were greeted and granted access into the facility by Caregiver Jeffrey De Jose, and introduced ourselves and stated purpose of the visit. LPAs asked that the administrator be informed of our arrival.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining area, family room, living room, laundry area in the garage, attached garage, and backyard. LPAs completed a walk through of facility and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPAs observed that there were 5 missing chair in residents room. A deficiency issued. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. LPAs observed that facility did not have sufficient supply of hygiene items for residents in care. A deficiency was issued. Water temperatures tested at 108.3 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. LPAs observed poster on display for personal rights, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets, inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were in secure cabinets and inaccessible to clients. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions.

Food Service: LPAs observed that the facility did not have a sufficient supply of perishable and non-perishable items. A deficiency was issued. The facility has sufficient supply of dishes, cups, and utensils were also stored properly. Emergency food and water were observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 10/14/2024 02:45 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/14/2024 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WALNUT SENIOR HOME II
FACILITY NUMBER: 361881024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above by not providing sufficient amount of food for 6 residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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The Administrator stated she will immediately complete the shopping needed and provide proof of food items purchased for residents in care. The Administrator will provide pictures and receipt of purchase via email.
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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/14/2024 02:45 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/14/2024 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WALNUT SENIOR HOME II
FACILITY NUMBER: 361881024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above by not having sufficient amount of hygiene products for the 6 residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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The Administrator agreed to provide proof of hygiene item purchased for residents in care by close of business on 10/18/2024. The Administrator agreed to submit proof via email with pictures and receipt of purchase.
Type B
Section Cited
CCR
87307(a)(3)(D)
Personal Accommodations and Services
(D) Hygiene items of general use such as soap and toilet paper.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above by not having sufficient amount of hygiene products for the 6 residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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The Administrator agreed to provide proof of hygiene item purchased for residents in care by close of business on 10/18/2024. The Administrator agreed to submit proof via email with pictures and receipt of purchase.
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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/14/2024 02:45 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/14/2024 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WALNUT SENIOR HOME II
FACILITY NUMBER: 361881024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above by not ensuring that all personnel file included general and medication training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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The Administrator agreed to provide proof of the training provided to all personnel staff and update personnel records by 10/29/2024.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Adminitrator did not comply with the section cited above by not ensuring that all 6 residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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The Administrator will provide to LPA proof of completed resident record which include the physician report, TB test, and appraisal. The proof shall be emailed to the LPA.
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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WALNUT SENIOR HOME II
FACILITY NUMBER: 361881024
VISIT DATE: 10/14/2024
NARRATIVE
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Yards/Outside: LPAs observed one shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPAs reviewed Administrator and staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPAs reviewed client files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans. LPAs observed incomplete resident record which included issues with the physician report, TB test, and appraisal. A deficiency was issued. LPAs observed staff personnel file missing general training and medical training. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and Appeals Rights were discussed and copies were provided to Administrator, Gulvarg Kaur.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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