366424264-9-28-2023-56-AS-ACON-CW5288-20230928170955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424264
Report Date: 09/28/2023
Date Signed: 09/28/2023 05:10:04 PM

Document Has Been Signed on 09/28/2023 05:10 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		FACILITY NUMBER:	366424264
ADMINISTRATOR:	KAUR, GULVARG		FACILITY TYPE:	740
ADDRESS:	291 E. WALNUT AVE.		TELEPHONE:	(909) 961-7119
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	6	CENSUS: 3	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Emile Malto, Staff Member		TIME COMPLETED:	05:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, Amber Coleman, (LPA) arrived unannounced at the Walnut Senior Home to conduct an Annual Inspection. LPA introduced self and stated purpose of the visit. LPA was greeted by Facility Staff, Emilie Malto and invited inside facility. LPA was asked to sign in. While signing in, LPA observed a COVID station which included PPE, hand sanitizers and information regarding infection control. All made accessible to those who visit the facility and its residents. LPA was provided a place to work then completed a walk through of the physical plant. Personnel Records/Training/and Staffing- LPA began review of employee records. Three (3) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights and training verification, and current administrator certification. Staff files found to be in compliance. Resident Rooms - Each resident bedroom can accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms: All bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Hand rails were observed near toilets and in showers/tubs. Bathrooms also observed to be clean and orderly.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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	FACILITY NUMBER: 366424264
	VISIT DATE: 09/28/2023

NARRATIVE

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Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA began review of resident records. Three (3) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables food on hand.

General: Disaster drills are completed every other month. Most recent disaster drill conducted June 2023. Fire Extinguisher last inspected March 2023

No deficiencies observed during today's visit. Technical Violations are being issued to address concerns noted within CARE Tool. An exit interview was conducted where this report was discussed and provided to the Facility Representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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