392700580-12-19-2025-27-AS-NWPN-DPHU47-20251219141441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700580
Report Date: 12/19/2025
Date Signed: 12/19/2025 02:16:03 PM

Document Has Been Signed on 12/19/2025 02:16 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	WALTERS RESIDENTIAL HOME CARE 3		FACILITY NUMBER:	392700580
ADMINISTRATOR/ DIRECTOR:	JOSEPH NIMENE		FACILITY TYPE:	735
ADDRESS:	1335 MINE ST		TELEPHONE:	(510) 688-3552
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 4		CENSUS: 4	DATE:	12/19/2025
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Joseph Nimene		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	TSP Overview Case management 809 for Walters On 12/19/2025, at 1:35pm, Licensing called a meeting with Walters Residential Care Home 3 to review the Technical Support Program's recent report and recommendations. Attending the meeting are representatives of licensing, Licensing Program Manager Liza King and Licensing Program Analyst Noel Wolf Petersen, facility representatives Administrator Joseph Nimene and Administrator Tanneh Koaven, Shift Lead Christopher Tieh, Administrator Moses Walters Sr., Administrator Carla Walters. Elizabeth Toscano, Servie coordinator from VMRC, Katina Richison from the Long Term Care Ombudsman organization. The report was reviewed. To paraphrase, it details TSP's efforts in support of increasing facility compliance in the specific topics of medication management, recordkeeping, and food services. The TSP Analyst provided resources and guidance: ~for conducting medication audits to reduce errors; a guide to medication room organization, a guide to laws, statutes, and regulations pertaining to medication requirements. ~for creating complete and current records for personnel and clients; a guide to personnel records organization, a guide for client records organization, a checklist tool for file maintenance, a checklist tool for referrals and potential clients. ~for meeting requirements related to preparation and storage of food; a checklist tool for food service requirements, a monthly monitory assessment tool for quality standards and kitchen safety. continued on c-page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 3	FACILITY NUMBER: 392700580
	VISIT DATE: 12/19/2025

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The report also details efforts in supporting general compliance with laws and regulations, the TSP Analyst provided resources and guidance:
~For overall health; the Compliance And Regulatory Enforcement Tool, the Technical Support Program Self-Assessment and Resource Guides, and California Department of Social Services-General Resources contacts

In summary, the report concludes with the recommendation that the facility should complete a self assessment using the tools and guidance provided on at least a quartly basis and record actions taken when issues are identified, subscribe to the CCLD information sharing service, consider affiliating with a providerorganization to share concerns and solutions.

A period for questions by the representatives of the facility and an exit interview was conducted. At the conclusion of the meeting, a copy of this report was read and given to the administrator.

Signature on file.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

LIC809 (FAS) - (06/04)

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