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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197601827
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:48:42 PM

Substantiated


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
06/03/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220603152736
FACILITY NAME:WALNUT ACRES RESIDENTIAL CAREFACILITY NUMBER:
197601827
ADMINISTRATOR:SUSAN CALDWELLFACILITY TYPE:
740
ADDRESS:22907 OXNARD STREETTELEPHONE:
(818) 348-2210
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator-Susan CaldwellTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff not wearing masks.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced initial 10-day complaint visit to this facility. The LPA met with Administrator Susan Caldwell and explained the reason for the visit.

During today’s visit, the LPA conducted a physical plant tour at 9:28 a.m.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
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 3
Control Number 29-AS-20220603152736
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: 06/06/2022
NARRATIVE
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Regarding the allegation: Staff not wearing masks.
It was alleged that on 5/10/2022, a visitor came into the facility and observed that staff were not wearing face masks. During today’s visit, the LPA observed staff not wearing face masks at time of arrival. The LPA’s observation supported claims from a credible witness that staff are not wearing masks when in close contact with residents. The LPA discussed masking guidelines with Administrator Susan Caldwell. Staff did put masks on immediately upon the LPA’s observation. Based on the investigation, there is sufficient evidence to support the claim that staff were not wearing the required personal protection equipment (PPE). This allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220603152736
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: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
87467(f)(2)
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87467 (f)(2) Basic Services. Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Reinforce the visitation policies and procedures with staff, specifically highlighting the mask-wearing policy. Inform the LPA when this has taken place, but no later than 6/10/2022.
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Based on evidence obtained, the licensee did not comply with the section cited above, as all staff were observed without their masks as required, which poses a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3