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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530198
Report Date: 04/10/2024
Date Signed: 04/10/2024 10:57:41 AM

Document Has Been Signed on 04/10/2024 10:57 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WALNUT SENIOR HOME IIIFACILITY NUMBER:
365530198
ADMINISTRATOR/
DIRECTOR:		KAUR, ASHDEEPFACILITY TYPE:
740
ADDRESS:433 EAST WALNUT AVETELEPHONE:
(909) 714-2119
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 0DATE:
04/10/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gulvarg Kaur-LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:06 AM
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Licensing Program Analyst (LPA) Michelle Echeverria , arrived at Walnut Senior Home III, to conduct an announced Pre-Licensing visit for licensure. LPA was greeted by licensee, Gulvarg Kaur. LPA introduced self and stated purpose of the visit. LIC200 application was submitted on 11/17/23 for (6) non-ambulatory residents. Fire Safety Inspection clearance was granted for (6) non-ambulatory residents on 12/19/23. LPA toured the facility inside and outside and observed the following:

Structure: Facility is a one story house with (4) resident bedrooms, (2) resident bathrooms, office/staff room, living room, dining area, kitchen, pantry, backyard, and attached garage.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.

Bedrooms: Two bedrooms accommodates two non-ambulatory residents in each room, and two bedrooms across the hallway bathroom accommodates one non-ambulatory resident in each room.

Bathrooms: The resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent, and chemicals are stored in locked cabinets/office. There was a pantry stocked with non-perishable food and perishable food found in the refrigerator. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the bathroom faucet measured at 106.6 degrees fahrenheit. A functional washer and dryer are located inside the garage.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WALNUT SENIOR HOME III
FACILITY NUMBER: 365530198
VISIT DATE: 04/10/2024
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Living/Family room: There was a furnished living room with reading books and a tv observed.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies stored in a closet.

Yards/Outside: A self-latching handle gate on the left side of the house that leads into the backyard. There are no firearms, ammunition, swimming pool or bodies of water observed. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan: Facility sketch, visiting rules, and personal rights were observed posted by the entrance.

General items: The smoke and carbon monoxide detectors were tested and are operable. There was two fully charged fire extinguishers observed. Resident/Staff records stored inside the locked office. First Aid kit with required components, and a locked area for medication storage was observed.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. LPA completed COMP III with the Licensee at the conclusion of the inspection.

Licensee will be notified once facility is licensed. An exit interview was conducted, and this report was discussed and provided to licensee, Gulvarg Kaur.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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