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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530198
Report Date: 03/25/2026
Date Signed: 03/25/2026 03:49:02 PM

Document Has Been Signed on 03/25/2026 03:49 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 IIIFACILITY NUMBER:
365530198
ADMINISTRATOR/
DIRECTOR:		KAUR, ASHDEEPFACILITY TYPE:
740
ADDRESS:433 EAST WALNUT AVETELEPHONE:
(909) 714-2119
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
03/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Gulvarg Kaur, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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On 3/25/2026 Licensing Program Analyst (LPA) LaVette Farlow, arrived unannounced at Walnut Senior Home III, to conduct an annual inspections. LPA was greeted by Caregiver Maria Santiago and granted entry into the facility. Maria notified Licensee, Gulvarg Kaur of LPA's arrival. LPA introduced self and stated purpose of the visit. The facility is licensed to house (6) non-ambulatory residents and hospice waiver/granted for six (6) residents. LPA toured the facility inside and outside and observed the following:

Physical Plant: Facility is a one story house with (4) resident bedrooms, (2) resident bathrooms inside the facility and a third bathroom outside, office/staff room, living room, dining area, kitchen, pantry, backyard, and attached garage. LPA observed the facility's temperatures to be comfortable and measured at 75 degrees Fahrenheit. LPA observed the hot water temperature in the bathrooms and residents bathrooms. The water temperature in the residents bathroom and common area bathrooms measured at 104.8, 106.6 and 110.6, which is within regulations. LPA observed bathrooms and found that showers and toilets are operable. Each bathroom contained adequate amounts of hygiene supplies and paper products. LPA observed that linens and hygiene items are enough for residents in care. Each resident room included lamps, night-lights dresser drawers, bedding and chairs and appropriate lighting to ensure residents comfort and safety. The facility is equipped with smoke alarms and carbon monoxide detectors. The facility maintains and conducts fire drills and earthquake drills quarterly. Last drill completed in 12/2025. No abnormal notes (LIC809C Continued)
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2026
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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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 III
FACILITY NUMBER: 365530198
VISIT DATE: 03/25/2026
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made. Fire Extinguishers were observed throughout the facility. Fire Extinguishers were last inspected November 14, 2025.
Food Service: Nonperishable and perishable food items observed were sufficient for number of residents in care. Food is being prepared and stored properly. Facility offers a variety of food options and snacks for residents. Staff maintain a food menu which is updated on a monthly basis.
Care & Supervision: The facility maintain a sufficient number of staff for care of residents 24 hour and 7 days a week. Facility keeps, toxins, sharps, and other hazardous items secured and inaccessible to residents in care and stored in a closets throughout the facility.
Record Review and Resident/Staff Files: LPA reviewed records for three (3) residents files currently living at the facility. Resident records are complete with updated physician reports, Needs and Services Plans, Admission Agreement, and Emergency Contact sheet. LPA observed one residents physician report was expired, but Licensee has maintained constant email contact with InnovAge to request updated report. LPA additionally reviewed three (3) staff files and three (3) out of (3) staff records reflect current CPR/First Aid Certification, Criminal Record Clearance, Health Screening Report, and TB test. All file were available for review and complete.
Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, and facility license are posted in a prominent place. Emergency Disaster Plan is current. Facility files are maintained in secure locations in the facility.
Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and locked in the staff office. LPA observed that the Licensee did not updated and maintained the residents centrally stored log. LPA observed an initial for a medication that is no longer being dispensed or stored for 1 out of 3 residents. A deficiency cited.

Based on observations, one deficiency cited per Title 22, California Code of Regulations. An exit interview was conducted and copy of this report LIC809, LIC809C, LIC809D, and appeal right reviewed and discussed, then provided to Licensee, Gulvarg Kaur.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2026 03:49 PM - It Cannot Be Edited


Created By: Lavette Farlow On 03/25/2026 at 03:24 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 III
FACILITY NUMBER: 365530198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in (1) one out of (3) three residents in care by not ensuring the centrally stored medication log is accurate and any discontinued medication is removed from the log. LPA observed the staff were still initialing for medication that is no longer being dispensed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2026
Plan of Correction
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Licensee agrees to conduct a training on the regulation, medication error and storage for all staff and submit a log of all participate. Also, a statement of understanding of the regulation by POC due date to LPA.
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: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
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