366424264-9-20-2024-56-AS-MRIO-D9ATY7-20240920150817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424264
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:08:23 PM

Document Has Been Signed on 09/20/2024 03:08 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: 5	DATE:	09/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Gulvag Kaur		TIME COMPLETED:	03:15 PM

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Licensing Program Analysts (LPAs) Mary Rico and Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Administrator Gulvarg Kaur and was granted entry to the facility. LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following:

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. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the kitchen to be at 105.6 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA audit (3) client's medication. During medication audit, LPAs observed the facility did not have resident’s PRN response documented and maintained in the resident's facility record for medication. A technical violation will be issued.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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: 09/20/2024

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LPA also reviewed one (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, one technical violation will be issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC9102) was discussed and provided to Facility Administrator Gulvarg Kaur.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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