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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206599
Report Date: 06/11/2021
Date Signed: 12/28/2021 09:11:34 AM

Document Has Been Signed on 12/28/2021 09:11 AM - 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 #2FACILITY NUMBER:
547206599
ADMINISTRATOR:JOHNSON, TIFFANY LFACILITY TYPE:
735
ADDRESS:20222 AVE 332TELEPHONE:
(559) 564-0295
CITY:WOODLAKESTATE: CAZIP CODE:
93286
CAPACITY: 4CENSUS: 4DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Staff, Isabelle Estrella TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual Inspection visit. LPA Williams met with Staff Isabelle Estrella. LPA Williams contacted Administrator Tiffany Johnson via phone who gave permission for Staff to guide facility tour and sign inspection report. No residents were present.

LPA Williams began the tour of the facility with the Staff at the front entrance.

LPA Williams observed visitor log-in sheet, temperature check, and disinfection station. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs are present.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked door. LPA Williams observed the following personal protective equipment in a storage; face shield, gloves, and masks. Staff records were reviewed for infection control training. LPA Williams observed all facility staff wearing masks.

No deficiencies were observed.

Exit interview was conducted with Staff and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2021
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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