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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700580
Report Date: 08/29/2025
Date Signed: 08/29/2025 03:50:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2025 and conducted by Evaluator Liza King
COMPLAINT CONTROL NUMBER: 27-AS-20250826102435
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 3FACILITY NUMBER:
392700580
ADMINISTRATOR:JOSEPH NIMENEFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:4CENSUS: DATE:
08/29/2025
ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tenneh WaltersTIME COMPLETED:
02:51 PM
ALLEGATION(S):
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Staff did not ensure the kitchen drawers are working properly
Staff didn't ensure chemicals were locked and inaccessible to residents
Staff do not ensure residents hygiene products are stored appropriately
Staff do not ensure the bathroom/shower curtain are free from mold
Staff do not ensure that residents blinds are in good condition
Staff do not ensure there is food of quantity to meet residents needs
INVESTIGATION FINDINGS:
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On this date, a meeting was conducted via Microsoft Teams to address observations during a facility visit conducted by VMRC. . Members present included Liza King, Licensing Program Manager, VMRC representatives Brian Bennett, Katina Richison, Elizabeth Toscano, Shannon Hernandez, Licensee Moses Walters SR, Tarloh Walters, Tanneh Koayen and Program Administrator Joseph Nimene
Items obsereved included: The kitchen cabinet drawers are broken, and the rollers are not functioning properly, making it difficult to open and close them. During todays meeting the licensee representative acknowledged the issue and confiormed that the drawers have been fixed.
Liquid Kirkland dish soap was left out on the kitchen sink. Clorox all-purpose cleaner was storedunder the upstairs bathroom sink in an unlocked cabinet. One resident was present during the observation and is not allowed access to these supplies unsupervised. Under the bathroom sink, a bucket containing the individual’s toothbrushes, toothpaste with out a cap, and mouthwash with out a cap. Next to the bucket was a cleaning sponge, handle scrub brush, and ripped-up toilet paper.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20250826102435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 3
FACILITY NUMBER: 392700580
VISIT DATE: 08/29/2025
NARRATIVE
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 The upstairs bathroom shower curtain has mildew and needs to be replaced. Along the shower edge, there is mildew present that requires cleaning or re-caulking. The upstairs bedroom blinds in the individuals room needs to be replaced. The blinds have dark spots and broken blind pieces missing.

As a result of this investigation, LPM finds the allegations to be (s) Substantiated -A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview conducted. A copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250826102435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 3
FACILITY NUMBER: 392700580
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2025
Section Cited
CCR
80087(g)
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(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.This was not met as evideced by:
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Licensee remioved items immediately during inspection. An sign will be posted regarding this Safety Practice.
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Liquid Kirkland dish soap was left out on the kitchen sink. Clorox all-purpose cleaner was storedunder the upstairs bathroom sink in an unlocked cabinet. One resident was present during the observation and is not allowed access to these supplies unsupervised.
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Type B
08/29/2025
Section Cited
CCR
80087(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This was not met as evidenced by
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The items were removed immediately. A new shower cuirtain and back ups will be prurchased staff will be trained on laundering the shower curtain when linen is laundered. Blinds have been replaced.
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The kitchen cabinet drawers are broken, and the rollers are not functioning properly, making it difficult to open and close them.Under the bathroom sink, a bucket containing the individual’s toothbrushes, toothpaste with out a cap, and mouthwash with out a cap. Next to the bucket was a cleaning sponge, handle scrub brush, and ripped-up toilet paper. Bedroom blinds (1) were observed to be broken
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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.
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250826102435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 3
FACILITY NUMBER: 392700580
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2025
Section Cited
CCR
85076
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85076(d)(1) Food Service
(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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Food was purchased on that day A menu which shows resident preferences will be provided by 090225
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This was not met as evideced by the Administror acknowledged there was not suffiecient food in vaeriety and expired foods were present.
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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.
SUPERVISORS NAME: Krystall Moore
LICENSING EVALUATOR NAME: Liza King
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4