197601827-4-27-2021-29-AS-JAPL-C2HW2F-20210428165417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197601827
Report Date: 04/27/2021
Date Signed: 04/27/2021 01:36:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2021 and conducted by Evaluator Aja Richardson

COMPLAINT CONTROL NUMBER: 29-AS-20210420155847

FACILITY NAME:	WALNUT ACRES RESIDENTIAL CARE		FACILITY NUMBER:	197601827
ADMINISTRATOR:	SUSAN CALDWELL		FACILITY TYPE:	740
ADDRESS:	22907 OXNARD STREET		TELEPHONE:	(818) 348-2210
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	04/27/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Susan Caldwell, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility has pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced 10-day visit to investigate the above allegation. LPA met with the Administrator Susan Caldwell at 10:45 am and explained the reason for the visit.

There are concerns that there is a pest problem and that residents have bite marks on their body. During today's visit, LPA conducted interviews with the Administrator, Staff, and residents currently living at the facility from 10:58 am to 12:05 pm. At 11:15 am, LPA Richardson took a tour of the facility. During tour LPA observed roach kiling bait throughout the kitchen area. Interviews conducted revealed that roaches were observed in the kitchen as recently as yesterday. Resident #1(R1) does have marks under their left arm that just developed within the last 2 days. The Administrator has put an anti itch cream and notified R1's case manager. The Administrator also stated that pest control comes on a routine basis and the last visit was 2/3/2021.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 29-AS-20210420155847

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE	FACILITY NUMBER: 197601827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/26/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Submit a more agressive schedule to licensing with the times that the pest control company will come out for the next 90 days.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above, as the facility has an issue with roaches and the facility has not has not had the pest control company come out since Feb. 3, 2021, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2021 and conducted by Evaluator Aja Richardson

COMPLAINT CONTROL NUMBER: 29-AS-20210420155847

FACILITY NAME:	WALNUT ACRES RESIDENTIAL CARE		FACILITY NUMBER:	197601827
ADMINISTRATOR:	SUSAN CALDWELL		FACILITY TYPE:	740
ADDRESS:	22907 OXNARD STREET		TELEPHONE:	(818) 348-2210
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	04/27/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Susan Caldwell, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Residents are over medicated
Staff left resident in soiled clothing for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced 10-day visit to investigate the above allegations. LPA met with the Administrator Susan Caldwell at 10:45 am and explained the reason for the visit.

Regarding the allegation residents are overmedicated there are concerns that staff are giving PRN medications excessively in order to not deal with certain behaviors. During today's visit, LPA conducted interviews with the Administrator, Staff, a private caregiver and residents currently living at the facility from 10:58 am to 12:05 pm. At 11:15 am, LPA Richardson took a tour of the facility and at 11:45 am, LPA revieved all of the medication records for the 5 residents who currently live at the facility The facility uses a Medication Administration Records (MARS) to document when medications are given. Based on interviews and medication review, medications appear to be given as prescribed. This allegation is Unsubstantiated at this time.
Continued on 9099c...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20210420155847

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE	FACILITY NUMBER: 197601827
	VISIT DATE: 04/27/2021

NARRATIVE

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To investigate the allegation that staff left resident in soiled clothing for an extended period of time, LPA conducted interviews with the Administrator, Staff, a private caregiver and residents currently living at the facility from 10:58 am to 12:05 pm. At 11:15 am, LPA Richardson took a tour of the facility and at 12:15 pm, LPA reviewed all of the facility records for the 5 residents who currently live at the facility. According to interviews conducted with residents and staff there are no concerns of resident's being left in soiled diapers. During today's visit there were 3 staff working and caring for the residents. According to staff interviews, residents are changed every 2 hours and more if needed. Residents interviewed stated they are well cared for and never left in soiled clothing. Based on this information this allegation is Unsubstantiated at this time.

Exit interview conducted. Report emailed to Administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 29-AS-20210420155847

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT ACRES RESIDENTIAL CARE	FACILITY NUMBER: 197601827
	VISIT DATE: 04/27/2021

NARRATIVE

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A doctor's appointment will be set up today to check R1's rash and although It is unknown whether the bites are from the pests, due to roaches being regularly observed in the kitchen this allegation is Substantiated at this time.

Based on interviews conducted stating there is a problem with roaches in the facility and pest control has not recently been out to spray facility this allegation is Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. The report was signed, however a copy of the signed report was emailed, along with the appeal rights.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC9099 (FAS) - (06/04)

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