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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 03/07/2024
Date Signed: 03/07/2024 04:29:47 PM

Document Has Been Signed on 03/07/2024 04:29 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:VICKY CROSSFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 110CENSUS: 71DATE:
03/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:17 PM
MET WITH:Vicky CrossTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding the incident report LPA received on 02/26/2024 regarding bedbugs at the facility. LPA met with Administrator, Vicky Cross, and explained the purpose of the visit.

Based on documentation, it revealed treatments was recently conducted for the common areas and resident's bedrooms. During today's visit, it was discussed that all positive resident bedrooms has been treated on Monday. It was further discussed that there was one additional room detected for bedbugs date of visit.

LPA and Administrator discussed the preventative steps facility is taking to eliminate bedbugs. LPA was informed that facility has stopped all move-in's until facility is cleared. Additionally, LPA and Administrator discussed implementing preventative treatments such as Aprehend and additionally, LPA advised facility to implement Personal Protective Equipment such as white hazmat pants and shoe booties, to prevent transfers of bedbugs from room to room.Administrator stated this matter will be discussed with Licensee.

No deficiencies cited. LPA will continue monitoring this matter.

Exit interview and a copy of the report will be provided via email to Administrator.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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