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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206600
Report Date: 04/11/2022
Date Signed: 04/11/2022 12:39:38 PM

Document Has Been Signed on 04/11/2022 12:39 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 #1FACILITY NUMBER:
547206600
ADMINISTRATOR:GARCIA, BRIANNAFACILITY TYPE:
735
ADDRESS:25401 ROAD 152TELEPHONE:
(559) 747-3319
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Brianna Garcia, AdministratorTIME COMPLETED:
12:00 PM
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On 04/11/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Lisa Gonzales. LPA toured facility with caregiver. Administrator Brianna Garcia arrived later during tour. There is currently one client present during tour.

Upon entry facility staff was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility.

LPA checked clients’ locked medications and observed a sample of 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 02/05/22. Fire drill date: 03/19/22. All clients’ room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. Cleaning supplies were stored and locked in cabinets in laundry room. The exterior tour was conducted. Side gate was self-closing and free of obstruction. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 04/18/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, and control of property. LPA received copy of Lic 500, Lic 610D, Lic 9020, facility sketch, and updated Administrator certificate during facility inspection.

Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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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