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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601827
Report Date: 07/25/2023
Date Signed: 07/25/2023 04:45:01 PM

Document Has Been Signed on 07/25/2023 04:45 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:
07/25/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Susan CaldwellTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility to conduct a required annual continuation visit. The LPA met with Administrator Susan Caldwell at approximately 1:20 p.m. and explained the reason for the visit.

Medication Audit: During today's visit, LPA Ascencio conducted a medication audit review for 5 residents. Medication audit revealed that 3 out of 5 residents did not have some medication centrally stored in their record.

Staff and Resident Interviews: Interviews were conducted with staff and resident beginning at 3:55 p.m. Interviews revealed understanding of regulations while interviews with residents revealed contentment at the facility.

1 citation a was issued during today's visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and copy of the report and appeal right were issued.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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 07/25/2023 04:45 PM - It Cannot Be Edited


Created By: Angel Ascencio On 07/25/2023 at 03:58 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: 07/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Admission Agreements
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87465(a)(6)
When requested by the prescribing physician or the Department, a record of dosages of medication which are centrally stored shall be maintained by the facility .

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above 3 out of 5 residents did not have the centrally stored medication and destruction record updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Administrator will conduct medication audit. Adminstrator will write a plan to continued medication review and audit to stay in compliance by 8/11/23.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023


LIC809 (FAS) - (06/04)
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