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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530411
Report Date: 10/07/2026
Date Signed: 10/07/2026 05:14:09 PM

Document Has Been Signed on 10/07/2026 05:14 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 1FACILITY NUMBER:
365530411
ADMINISTRATOR/
DIRECTOR:		KAUR, GULVARGFACILITY TYPE:
740
ADDRESS:241 EAST CHAPARRAL STREETTELEPHONE:
(909) 258-2917
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
10/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:23 PM
MET WITH:Gulvarg "Maya" Kaur, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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On 10/7/2026 Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required Comprehensive Annual Inspection. LPA was greeted and granted access into the facility by Caregiver, Masria "Ani" Andriani, and introduced self and stated purpose of the visit. LPA asked Ani to informed the Administrator of LPA's arrival. LPA later meet with Gulvarg "Maya" Kuar, Administrator and explained the purpose of the visit.

The facility has 4 bedrooms, which one room is utilized for staff, 3 bathrooms, kitchen, dining area, family room, living room, staff office, 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 resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident 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 117.5 and 115.9 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher, which was last inspected on 5/22/2026. 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 secure in the cabinets, inaccessible to residents. There was a designated storage space for resident/staff files. Medications were in secure cabinets and inaccessible to residents. The facility maintained a first aid kit and book. The first aid book was out dated and has a copy right date of 2008. A Technical advisory issued. 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 and were also stored properly. Emergency food and water were observed.
Nedra Brown
Lavette Farlow
DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2026
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 1
FACILITY NUMBER: 365530411
VISIT DATE: 10/07/2026
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Yards/Outside: LPA observed one shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPA reviewed Administrator and 3 staff files for First Aid/CPR certification, criminal record clearance, training, health screenings and TB test. All personnel files appeared to be well maintained. LPA reviewed 3 residents files for admissions agreements, pre-admissions appraisals, physician's reports, TB test results, and care plans. All residents files appeared to be well maintained. LPA conducted an audit of 3 residents MARs. 1 out of 3 residents MARs had the following concerns: R1 did not have a bubble pack or a pill bottle that listed R1's vitamin D3 prescription medication, the facility did have a MARs but the Licensee stated that the medication was issued on the 30th of September, but the staff signed for it on October 1, 2026. Licensee was not clear on the date or day the medication is scheduled to be dispensed. A deficiency cited.

Facility file review was conducted for the following records: Infection Control Plan, Emergency Disaster Plan, Liability Insurance, and Fire Drills. The facility files appeared to be maintained and in order.

One deficiency and one Technical advisory 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: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/07/2026 05:14 PM - It Cannot Be Edited


Created By: Lavette Farlow On 10/07/2026 at 03:54 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 1
FACILITY NUMBER: 365530411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.

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 out of 3 residents in care by not ensuring the facility maintained the records for the medication, medication records, MARs, and centrally stored medication log for R1 vitamin D3 prescription. The Licensee did not have a bubble pack or medication bottle for the medication listed. The bubble pack did not have the vitamin D3 listed it only had the vitamin B. Licensee also stated that the medication was given on the 30th of the month, but signed for on the first of October. Licensee did not have anything to show proof of the prescription which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2026
Plan of Correction
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Licensee agrees to review the regulation cited and submit a statement of understanding to LPA by POC due date. Licensee will complete a medication training with all staff either from InnovAge or online course, and provide proof of completion to LPA by POC due date.
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: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
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