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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206599
Report Date: 05/17/2024
Date Signed: 05/17/2024 06:32:45 PM

Document Has Been Signed on 05/17/2024 06:32 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 #2FACILITY NUMBER:
547206599
ADMINISTRATOR/
DIRECTOR:		JOHNSON, TIFFANY LFACILITY TYPE:
735
ADDRESS:20222 AVE 332TELEPHONE:
(559) 564-0295
CITY:WOODLAKESTATE: CAZIP CODE:
93286
CAPACITY: 4CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Tiffany Johnson
Kristal Gomez		TIME VISIT/
INSPECTION COMPLETED:
06:41 PM
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On 5/17/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA Medina arrived, stated purpose of visit, and allowed entrance by Administrator, Tiffany Johnson. Kristal Gomez, House Manager also present during inspection.

Currently, 4 residents are in placement. All residents were at Day Program at time of inspection and afternoon outing at time of inspection.

Facility tour conducted with Administrator. Facility observed to be well lit, clean and odor free. All common areas have adequate seating available. Resident bedrooms toured, all bedrooms observed to have required furnishings. Bathrooms toured, showers observed to have non-slid mats and grab bars. Water temperature during facility inspection measured at 113 degrees F. Kitchen toured, all sharps observed to be locked and secured in lock box. Facility observed to have a 2-day supply of perishable and 7-day of non-perishable available. Medication observed to be locked and secured in medication cabinet. Medication observed to be administered as ordered. Smoke detectors and carbon monoxide detector observed operational during inspection. Fire extinguisher present with a purchase date of 2/05/24.

Outside of facility toured. All exits open free of obstruction. Perimeter of back yard is secured with a fence and free of obstruction.

Staff and resident files reviewed.

LPA received copies of LIC 500, LIC 610, and surety bond during inspection visit.

Exit interview conducted. No deficiencies cited.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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