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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206599
Report Date: 05/05/2022
Date Signed: 05/05/2022 11:54:18 AM

Document Has Been Signed on 05/05/2022 11:54 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:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Tiffany JohnsonTIME COMPLETED:
11:59 AM
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On 4/21/2022, LPA Medina conducted an unannounced Annual Required Inspection. LPA contacted Administrator, Tiffany Johnson by telephone and she arrived a short tine later to conduct inspection visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors enter through front door.

Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to resident and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid, hand washing posters observed near sink, paper towels and hand soap available. Shower/tub has non-skid surface and grab bars. All residents have private bedrooms, all bedrooms observed to have required furnishings.

Fire extinguisher present and has a purchase date of 01/19/2022. Carbon monoxide detector and smoke detectors present and observed to be operational during today's inspection. Water temperatures measured at 114 degrees F.

Food supply was observed to be adequate for residents in care. Cleaning and Personal Protective Equipment (PPE) supplies were checked. The following PPE items observed to be stored; face shields, gloves, and masks, and gowns.

LPA received copies of Administrator Certificate, LIC 500, and LIC 9020 during facility inspection.

No deficiencies observed during today's inspection. Exit interview was conducted with Administrator and a copy of this report was provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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