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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206600
Report Date: 05/07/2024
Date Signed: 05/20/2024 08:34:27 AM

Document Has Been Signed on 05/20/2024 08:34 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:WALNUT GROVE HOUSE, INC. DBA LEWIS GRAVES ARF #1FACILITY NUMBER:
547206600
ADMINISTRATOR/
DIRECTOR:		GARCIA, BRIANNAFACILITY TYPE:
735
ADDRESS:25401 ROAD 152TELEPHONE:
(559) 747-3319
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 6CENSUS: 4DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Tami Leyva TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 5/7/2024, Licensing Program Analyst LPA K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by House Manager Kristal Gomez. Staff contacted Administrator Tami Leyva who arrived a short while. LPA conducted tour with Staff. The facility was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. Sufficient perishable food supplies observed. Fire extinguisher in the Kitchen was last serviced on 01/25/2024 and was fully charged. All common areas were properly furnished and well-lit throughout. Medications, First Aid, and Sharp items locked in the kitchen cabinets. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA toured 4 resident rooms and an office. All client bedrooms toured and observed to be adequately furnished. Extra linens observed in the hallway closet. LPA toured laundry area which appeared clean. LPA observed cleaning supplies and chemicals unlocked in cabinet next to laundry. LPA observed paint bucket unlocked near laundry area. The exterior tour was conducted. Car wash bottle observed unlocked in the garage. The backyard was observed to have sufficient. A covered area is provided during the summer. Medication was reviewed. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. Last fire drill completed on 4/16/2024.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22,
Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/14/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a printed copy was provided including appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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Document Has Been Signed on 05/20/2024 08:34 AM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 05/07/2024 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: WALNUT GROVE HOUSE, INC. DBA LEWIS GRAVES ARF #1
FACILITY NUMBER: 547206600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 areas observed with unlocked paint cans, chemicals, and cleaning supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Staff locked items immediately. Administrator to complete in service training and submit documents by 5/14/2024
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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