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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411433
Report Date: 11/04/2025
Date Signed: 12/29/2025 08:30:53 AM

Document Has Been Signed on 12/29/2025 08:30 AM - It Cannot Be Edited

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
, CA 92507
FACILITY NAME:WALNUT HOMEFACILITY NUMBER:
366411433
ADMINISTRATOR/
DIRECTOR:		IRMA RODRIGUEZFACILITY TYPE:
735
ADDRESS:6086 WALNUT AVENUETELEPHONE:
(909) 248-0450
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 6DATE:
11/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Irma Rodriguez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Administrator Irma Rodriguez. LPA explained the nature of today's visit. This home is designated as a level 3 home by IRC.

LPA accompanied with Ms Rodriguez, conducted a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. There are no pools or other bodies of water located on the premises. There are no ammunition or firearms kept in the home. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at 108.5 degrees Fahrenheit in all resident bathrooms. There are grab bars for each toilet, bathtub and shower used by residents.
Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods.

Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs.

Record Review: LPA requested and reviewed (6) resident and (6) staff files. LPA reviewed staff files for current CPR/1st aide certificates, TB results, and required training's. LPA reviewed client files for admissions agreement, physician report, and IPP.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Javier Prieto
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: WALNUT HOME
FACILITY NUMBER: 366411433
VISIT DATE: 11/04/2025
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Administration: The last fire drill was conducted on 10/05/2025 and the last disaster drill was conducted on 10/16/2025. LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation.

Medical Related Services: Prescriptions and non-prescription PRN medications contain a signed and dated written order from a physician. Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions.

No deficiencies cited. An exit interview was conducted where this report was provided and discussed with Ms Rodriguez.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Javier Prieto
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
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