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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881024
Report Date: 10/16/2023
Date Signed: 10/16/2023 02:59:38 PM


Document Has Been Signed on 10/16/2023 02:59 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, 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:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Gulvarg Kaur, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Walnut Senior Home II unannounced to conduct an Annual Inspection of the facility. LPA was greeted by Caregiver/Staff, Jeffrey De Jose, then granted entry. LPA was then greeted by Administrator, Gulvarg Kaur who accompanied LPA on a walk through the facility.

The facility is a Residential Care Facility for the Elderly. The facility is approved for six, (6) non-ambulatory residents, 1 bedridden and has a Hospice Waiver in place for four, (4) residents. The facility is comprised of 4 Resident Rooms, 1 Staff Room, 1 Office, Living/Dining Room, Kitchen, 2 Bathrooms, Backyard and attached garage.

Personnel Records/Training/and Staffing- LPA reviewed three, (3) employee records for first aid certification, fingerprint/criminal background clearances, personnel/job application, health screening, TB test results, employee rights and training verification, and current administrator certifications. LPA observed that all staff records were complete with all required annual documents.

Resident Rooms - Each resident bedroom accommodate both ambulatory and non-ambulatory residents. All resident bedrooms were adequately furnished with bed/mattress, chair, large closets, appropriate linens, adequate lighting, and an operational smoke/carbon monoxide alarms.

Bathrooms: All bathrooms have a functional toilets, wash basins, and showers with an adequate supply of towels, toilet paper, and toiletries. Hand rails and non-slip grip mats were observed accessible for use. Bathrooms were observed to be clean and orderly. Water temperature tested and found to be within regulatory limits.

Please see LIC809-C
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WALNUT SENIOR HOME II
FACILITY NUMBER: 361881024
VISIT DATE: 10/16/2023
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Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed three, (3) resident records for admissions agreements, medical assessments, annual TB test results, consent forms, identification/emergency information, pre-appraisals, needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed completed documents in each of the resident files.

Food Service- LPA observed the refrigerator to have adequate amounts of food for the capacity of residents in care. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables food on hand. LPA observed a weekly food menu posted on the refrigerator; which offered a variety of meals and snacks for residents in care. Food prep areas are clean and free of clutter. Clean and properly stored dishes and utensils were also observed. Sharp objects are located within a lock box inaccessible to residents.

General: Disaster drills are completed every three months. Last fire/disaster drill was completed September 2023. LPA observed a fully charged fire extinguisher last inspected July 2023.

No deficiencies observed during today's visit. An exit interview was conducted where this report was reviewed discussed then provided to Administrator Gulvarg Kaur.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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