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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803700
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:21:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2025 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250123120517
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: 12DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Celina Vasquez - CaregiverTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff do not ensure facility is maintained clean and sanitary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Celina Vasquez and explained the reason for the visit.

The investigation consisted of the following: LPA requested resident and staff roster. LPA conducted a tour of the facility with Selena Vasquez. LPA interview 4 residents and 4 staff. LPA requested copy of menu, Nine resident’s physician’s reports.

Regarding allegation: Staff do not ensure facility is maintained clean and sanitary. It is alleged facility was not disinfected for a week due to lack of cleaning supplies, and the carpets are dirty. LPA conducted tour of the facility and observed 9 out of 14 rooms with carpets with stains of different sizes from small circle spots to spots of the size of a grapefruit in each room #1,2,3,4,6,7,9,2,13,14. Bathroom #2 was observed with water build up around the shower handle and the soap build up under the grab bar and corners of the shower. (CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20250123120517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLA
FACILITY NUMBER: 197803700
VISIT DATE: 01/30/2025
NARRATIVE
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LPA observed housekeeper’s caddy with comet bleach and less than half bottle of Windex, storage area was observed with one gallon of laundry detergent, one Windex bottle, and some bottles of carpet cleaner. Housekeeper showed LPA an additional multipurpose cleaner. Interviews conducted with residents revealed, staff clean residents’ rooms daily. However, they cannot remember when the carpet was clean. Interviews with manager revealed supplies have been purchase as requested by staff. Upon asking the staff if there were any additional cleaning supplies, they stated there weren’t any other cleaning supplies. Per staff they use what they have available to clean. Even though manager may purchase cleaning supplies, at the time of the visit there were no sufficient cleaning supplies to properly clean and disinfect different areas of the facility.
Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted an a copy of this report, LIC9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2025 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250123120517

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: 12DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Celina Vasquez - CaregiverTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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2
3
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5
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9
Staff do not ensure there is enough food at the facility for residents
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Celina Vasquez and explained the reason for the visit.

The investigation consisted of the following: LPA requested resident and staff roster. LPA conducted a tour of the facility with Selena Vasquez. LPA interview 4 residents and 4 staff. LPA requested copy of menu, Nine resident’s physician’s reports.

The investigation revealed the following: Regarding allegation: Staff do not ensure there is enough food at the facility for residents. It is alleged facility constantly runs out of food. During tour of the facility, LPA observed refrigerator with condiments, tortillas, half a watermelon, 1 gallon of milk, hamburger bread, 1 bag of lettuce, and a whole lettuce, carrots, and squash. In Emergency food supplies area, LPA observed emergency food supplies, bin for sugar with one inch of sugar, and beans bin empty. (CONTINUED LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20250123120517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLA
FACILITY NUMBER: 197803700
VISIT DATE: 01/30/2025
NARRATIVE
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Freezer was observed with 8 frozen dinners, one bag of hamburger patties, two pounds of ground beef, one turkey, one chicken, 4 containers of ground turkey, one pack of breast chicken, one pack of beef chunk of 1.35 lbs. LPA observed variety of can foods, and dried goods such as lentils, beans, rice, and pasta in the pantry. LPA reviewed the following documents: facility’s three rotating menus, which provides a variety of foods, per facility schedule two staff are assigned to the kitchen throughout the week. Kitchen staff’s training on food preparation were provided on 2014.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250123120517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLA
FACILITY NUMBER: 197803700
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2025
Section Cited
CCR
83033
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
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Administrator will provide staff with cleaning, sanitation training, will have proper cleaning of residents' rooms carpets, and will ensure that proper cleaning supplies are available at the facility at all times, and submit a copy of training to the department by POC due date: 2/6/25.
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Based on observations licensee did not ensure staff have sufficient cleaning supplies and clean and disinfect all facility areas which poses a potential risk to the health, safety, or personal rights of the persons in care.
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Administrator purchase bleach and floor cleaning at the time of the visit and place and order multiple purporse cleaner.
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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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5