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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700580
Report Date: 08/29/2025
Date Signed: 08/29/2025 03:46:34 PM

Document Has Been Signed on 08/29/2025 03:46 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 3FACILITY NUMBER:
392700580
ADMINISTRATOR/
DIRECTOR:		JOSEPH NIMENEFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 4DATE:
08/29/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On this date, a meeting was conducted via Microsoft Teams to address an incident that occurred on 08/24/25 which was not reported to licensing or VMRC which put the client in immediate risk. 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.
On 8/24/25, R1 eloped from Walters Residential Home #3. Police contacted VMRC on the same date requesting assistance to identify the individual. No injuries were noted. Necessary parties including licensing were not notified by the facility regarding R1s elopement on 8/24/25 within the required timeframe.
During todays meeting the additional following issues were discussed:
Staff 1 denied being present during the incident, however staff interviews revealed S1 was present.
Required staffing ratio per Title 17
Licensee/staff familiarity and implementation of client IPP's
Resident Rights re: Food choices
Quality and Quantity of food
Reporting Requirements - licensee was reminded that incident reports(IRs) may be faxed into 916-263-4744 or emailed to CCLASCPSacramentoRO@dss.ca.gov
IRs should not be emailed directly to an LPA.
The Licensee agreed to provide updated LIC200 and LIC500, Organizational Charts for each facility and a LIC309.
Based on todays findings citations are issued on the attached D page. An exit interview was conducted with Tenneh Walters and a copy of the report with the appeal rights provided via mail please return signed copy to Liza.King@dss.ca.gov
NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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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Document Has Been Signed on 08/29/2025 03:46 PM - It Cannot Be Edited


Created By: Liza King On 08/29/2025 at 09:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
09/01/2025
Section Cited
CCR
80078(a)

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Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This was not met as evidenced by:
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Training willl be provided to staff on what supervision should look like and policies on what to do in case of an elopement. This will be submitted to Noel.WolfPetersen@dss.ca.gov
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On 08/24/25 R1 eloped from the facility. This is an immediuate risk to clients in care.
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Type B
09/30/2025
Section Cited
CCR80061(a)

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(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. This was not met as evidenced by
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All staff will recieve IR training for an outsourced vendor within 30days.
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The licensee failed to report an incident where a resident eloped from the facility
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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.
Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:
Liza King
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/29/2025 03:46 PM - It Cannot Be Edited


Created By: Liza King On 08/29/2025 at 09:45 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
09/02/2025
Section Cited
CCR
80064(a)(3)

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(a) The administrator shall have the following qualifications:(3) Knowledge of and ability to comply with applicable law and regulation. This was not met as evidenced by:
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Licensee will submit an update LIC500 that meets the staffing requirements by
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The Administrator failed to provide staffing based on the needs of the clients identified in the IPP per Title 17 59006
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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.
Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:
Liza King
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
Page: 4 of 4