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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592101
Report Date: 12/05/2023
Date Signed: 12/05/2023 01:33:53 PM

Document Has Been Signed on 12/05/2023 01:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WALNUT HOME CAREFACILITY NUMBER:
191592101
ADMINISTRATOR:RABENA, R. & J.FACILITY TYPE:
740
ADDRESS:654 BONNIE CLAIRE DRIVETELEPHONE:
(626) 964-5215
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 6CENSUS: 6DATE:
12/05/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Richard Rabena, LicenseeTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to finish the annual inspection. LPA met with licensee/administrator, Richard Rabena, and explained the reason for the visit.

During the visit today, LPA completed the remainder of the inspection and the following were reviewed:
Staffing: The facility has sufficient staffing to meet the needs of the residents. All staff members have current CPR & First Aid certificates. Per the licensee, there is backup staffing if needed.
Personnel Records-Training: LPA reviewed 3 Staff files. The administrator's (Richard Rabena) certificate expires on 7/27/25. Staff have fingerprint clearance and associated to the facility. Staff files have the required documents such as personnel record, health screening with TB results, employee rights form, and in-service training. Staff also have appropriate dementia care training.
Resident Records-Incident Reports: LPA reviewed 6 resident files that are maintained at the facility. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, preappraisal form, and personal rights form. The physician's report for Resident #3 diagnosed with dementia is not current.
Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff.
Planned Activities: Facility has sufficient space to provide indoor and outdoor activities to accommodate residents who are physically handicapped.
Incidental Medical and Dental: LPA reviewed 6 resident medications and there were no discrepancies observed.
Residents with Special Health Needs: Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are no residents currently with prohibited or restricted health conditions. No residents are using oxygen equipment.
A deficiency is issued on the LIC809D. An exit interview was held. A copy of this report along with appeal rights are given to Mr. Rabena.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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 12/05/2023 01:33 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 12/05/2023 at 01:12 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WALNUT HOME CARE
FACILITY NUMBER: 191592101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents which poses a potential health and safety risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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The licensee shall schedule a medical appointment for Resident #3 and obtain an updated physician's report by due date 12/19/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
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