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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206297
Report Date: 06/13/2024
Date Signed: 06/13/2024 09:29:42 PM

Document Has Been Signed on 06/13/2024 09:29 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:WALNUT GROVE HOUSE, INC. DBA LEWIS GRAVES ARF #3FACILITY NUMBER:
547206297
ADMINISTRATOR/
DIRECTOR:		LEYVA, TAMIFACILITY TYPE:
735
ADDRESS:3143 DOUGLASTELEPHONE:
(559) 732-4594
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 4DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Administrator (Admin) Tami LeyvaTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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An Annual visit was conducted by Licensing Program Analyst (LPA) Mcclurg. Licensing Program Analyst (LPA) K. Mcclurg met with Administrator (Admin) Tami Leyva. LPA & Admin had met before on previous visits.

Physical plant toured. Dining & Living rooms sufficiently furnished with adequate lighting. Sufficient supply of food on the premises. Resident rooms have sufficient furnishings with Adequate lighting. Resident bathrooms have working fixtures. Facility at a comfortable temperature.

Sufficient storage for keeping hazardous items including cleansers, chemicals, etc. to be inaccessible to clients. Medications organized & inaccessible to clients.

Outside area has no bodies of water (Pool, spa, fountain, etc.) on the premises. Interior & exterior passageways observed to be free from obstruction.

Smoke detectors & carbon monoxide detectors operational. Fire extinguisher service date: 1/25/24. Date of last disaster drill conducted: 5/28/24.

Exit interview conducted with Admin. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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