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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803700
Report Date: 10/30/2023
Date Signed: 10/30/2023 05:44:59 PM

Document Has Been Signed on 10/30/2023 05:44 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WALNUT VILLAFACILITY NUMBER:
197803700
ADMINISTRATOR:MICKLE, VICKIEFACILITY TYPE:
740
ADDRESS:13975 TELEGRAPH RD.TELEPHONE:
(562) 777-7200
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 20CENSUS: 13DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Celina VasquezTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the Required annual inspection. On today's visit LPA met with Administrator, Celina Vasquez, who assisted with the visit.

LPA Rea used the inspection tool, and toured the facility inside and out, reviewed food supply, reviewed staff files, resident files, and reviewed a portion of resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathroom is clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. The hot water temperature measured at 118 degrees F. There is a sufficient amount of perishable and non perishable food supply. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors, and carbon monoxide detectors located throughout the facility, tested and operating. Signal system was tested, and operational. LPA observed infection control signs posted and sufficient PPE supplies. The last fire drill was held on 10/5/23.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies cited. Exit interview held and a copy of the report provided to Ms.Vasquez.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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