<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601827
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:47:06 PM

Document Has Been Signed on 06/06/2022 02:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:WALNUT ACRES RESIDENTIAL CAREFACILITY NUMBER:
197601827
ADMINISTRATOR:SUSAN CALDWELLFACILITY TYPE:
740
ADDRESS:22907 OXNARD STREETTELEPHONE:
(818) 348-2210
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator-Susan CaldwellTIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elsie Campos arrived at the facility to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Facility Administrator Susan Caldwell at approximately 9:15 a.m. and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside at approximately 9:28 a.m., with Administrator Susan Caldwell., to ensure that there are no health and safety hazards.

BEDROOMS: There are (5) bedrooms designated for resident use. Bedroom #1 is single occupancy with no private bathroom and an exit to the exterior. Bedroom #2 is single occupancy with no private bathroom and no exit to the exterior. Bedroom #3 is a shared room containing two beds, two closet spaces with outdoor access and a shared bathroom. Bedroom #4 is single occupancy with a private bathroom and a direct exit to the exterior. Bedroom #5 is single occupancy with a private bathroom and a direct exit to the exterior. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use.

BATHROOMS: Resident bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products however (1) bathroom was not restocked at the time of observation. The administrator stocked the bathroom immediately upon observation. Bathroom hot water measured between 110.3 degrees Fahrenheit and 114.4 degrees Fahrenheit between 9:32 a.m. and 9:50 a.m. storage space closet in hallway was observed at 9:36 a.m. containing clean linens for resident use.

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827
VISIT DATE: 06/06/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
KITCHEN/LAUNDRY: At 9:40 a.m., the LPA toured the Kitchen and Laundry area. Appliances were clean, sanitary and in operable condition. The facility has a sufficient supply of perishable and non-perishable foods. At approximately 9:41 a.m. knives were observed to be accessible in an unlocked kitchen cabinet and at approximately 9:45 a.m. knives were observed on a dish rack and accessible to residents in care. At approximately 9:42 a.m. the LPA observed a bottle of Ajax cleaning powder unlocked under the kitchen sink. The administrator confirmed that the knives were left out after it was used to prepare breakfast in the morning. The cabinets were unlocked because staff were actively using the kitchen. At the time of the LPA’s observation the kitchen was clean and unattended by staff. At approximately 9:43 a.m. the LPA observed the laundry closet containing detergent, cleaning supplies and disinfectants to be unlocked. The administrator was reminded by the LPA that cleaning supplies and knives should be inaccessible to residents and remain locked at all times.

BACKYARD: At 9:53 a.m. the LPA toured the backyard area. The backyard has a covered outdoor area equipped with furniture for resident use. Furniture was observed to be in good repair. There were no bodies of water noted. The LPA observed a locked shed in the backyard which was inaccessible to residents at the time of the visit.



HALLWAY: At approximately 9:43 a.m., the LPA observed a locked bathroom room in the kitchen hallway containing all centrally stored medications. Medications were observed to be locked and secured at the time of the visit. At 10:03 a.m. smoke and carbon monoxide detectors were observed in the hallway and throughout the facility. At 10:05 a.m. the administrator tested the fire alarm system and the LPA observed it to be operating appropriately in all bedrooms and common areas at the time of the visit. The fire extinguisher was observed to be full and last serviced on 3/29/2022.

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827
VISIT DATE: 06/06/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
GARAGE: At approximately 10:10 a.m., the LPA toured the detached garage which is used as the facility office. The garage was free of obstructions and the cabinets were properly secured at the time of the visit.

INFECTION CONTROL: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. There was an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The LPA conducted an unannounced initial 10-day complaint visit in conjunction with today's annual visit, complaint control number 29-AS-20220603152736 and cited for deficiency found regarding masking. The LPA reminded the Licensee that masking protocols are still in place including vaccination requirements, visitation, and testing protocols.

An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/06/2022 02:47 PM - It Cannot Be Edited


Created By: Elsie Campos On 06/06/2022 at 01:36 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE
FACILITY NUMBER: 197601827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation interview, the licensee did not comply with the section cited above as (2) staff were not associated to the facility and (1) staff did not have a cleared background check which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
1
2
3
4
The Adminsitrator agreed to do the following:
1. Submit appropriate paperwork for the two staff and confirm that the staff are associated to the facility.

Civil penalties assessed.
Type A
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as knives were observed to be accesible in an unlocked cabinet in the kitchen and accessible on a dish rack on the kit hen counter. Cleaning solutions, detergent and disinfectants were observed to be unclocked and acessible in the kitchen hallway laundry closet which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
1
2
3
4
The Administrator agreed to the following:
1. Immediatley secure all knives and cleaning solutions. Plan of correction met at the time of the visit.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6