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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881024
Report Date: 11/18/2025
Date Signed: 11/18/2025 12:47:18 PM

Document Has Been Signed on 11/18/2025 12:47 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WALNUT SENIOR HOME IIFACILITY NUMBER:
361881024
ADMINISTRATOR/
DIRECTOR:		KAUR, GULVARGFACILITY TYPE:
740
ADDRESS:490 EAST WALNUT AVENUETELEPHONE:
(909) 714-2119
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 5DATE:
11/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Gulvarg Maya Kaur, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:53 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA were greeted and granted access into the facility by Caregiver, Roselina Mardiana and introduced self and stated purpose of the visit. LPA asked Roselina to informed the Administrator of LPA's arrival.

The facility has 4 bedrooms, 1 staff room, 2 bathrooms, kitchen, dining area, family room, living room, laundry area in the garage, attached garage, and backyard. LPA completed a walk through of facility, review of records, and conducted a random audit of the medication.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. LPA observed that facility has a sufficient supply of hygiene items for residents in care. Water temperatures tested at 112.9 and 118.7 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. LPA observed poster on display for personal rights, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets, inaccessible to clients. At 10:15 AM LPA was completing a tour of the kitchen and observed in the drawer a pair of scissors and a knife/box cutter. LPA advised caregiver to secure the items. A deficiency cited. There was a designated storage space for client/staff files. Medications and first aid kit were in secure cabinets and inaccessible to clients. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions.

Food Service: LPA observed that the facility has a sufficient supply of perishable and non-perishable items. The facility has sufficient supply of dishes, cups, and utensils were also stored properly. Emergency food and water were observed.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/18/2025 12:47 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/18/2025 at 12:01 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WALNUT SENIOR HOME II
FACILITY NUMBER: 361881024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring that all scissor and knifes/box cutter were secured and locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2025
Plan of Correction
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Administrator agrees to complete a training with all staff regarding securing sharps and complete a statement of understanding of review of the regulation cited with a list of all staff who have completed the training to LPA by 12/2/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WALNUT SENIOR HOME II
FACILITY NUMBER: 361881024
VISIT DATE: 11/18/2025
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Yards/Outside: LPA observed one shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. LPA observed fruit and vegetables trees in the backyard.

Record Review: LPA reviewed Administrator and 2 staff files for First Aid/CPR certification, criminal record clearance, training, health screenings and TB test. LPA reviewed 3 residents files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans. Personnel records and residents file appeared to be complete and in order.

One deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and Appeals Rights were discussed and copies were provided to Administrator, Gulvarg Maya Kaur.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC809 (FAS) - (06/04)
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