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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803700
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:23:00 PM

Document Has Been Signed on 01/30/2025 03:23 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 VILLAFACILITY NUMBER:
197803700
ADMINISTRATOR/
DIRECTOR:		MICKLE, VICKIEFACILITY TYPE:
740
ADDRESS:13975 TELEGRAPH RD.TELEPHONE:
(562) 777-7200
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 20CENSUS: 12DATE:
01/30/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Celina Vasquez - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted a case management visit during a complaint investigation visit to note additional deficiencies. LPA met with Celina Vasquez and explained the reason for the visit.

During the facility tour LPA observed the following deficiencies:
  • Auditory devices in exit doors were observed off when entering the facility and doing the tour of the facility. Facility serves and has residents with dementia.

  • Seven residents' physician's reports were reviewed and 1 resident has a low sodium, 2 residents have a mechanical, and 1 resident has a soft diet. LPA observed food preparation and served for lunch and there was no distinction on the meals served. LPA asked staff in charge if they had any special diets and stated "no." LPA observed several dinner meals in the freezer.

  • LPA observed room #6 being used as a caregiver room.

Deficiencies were noted on LIC 809D and a technical advisory was provided per Title 22 Regulations.

A copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/30/2025 03:23 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/30/2025 at 02:28 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 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
87555(b)(7)

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87555 General Food Service Requirements
(b) The following food service requirements shall apply: (7)Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
This requirement is not as evidence by:
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Administrator will provide training to kitchen staff that covers, special diets, servings, and preparation and will submit a copy to the department by POC due date: 2/6/25.
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Based on observations and interviews conducted licensee did not ensure staff were providing meals to the residents based on the diets noted by the physician which poses a potential risk to the persons health, safety, and personal rights of the persons in care.
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Type B
02/06/2025
Section Cited
CCR87705(j)

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87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidence by:
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Administrator will provide training to staff on Dementia section 87705 and will provide a copy to the department by POC due date: 2/6/25.
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Based on observations licensee did not ensure staff maintained the auditory devices on at all times which poses a potential risk to the health, safety, or personal rights of the persons in care.
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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:Mary G Flores
LICENSING EVALUATOR 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


LIC809 (FAS) - (06/04)
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