197608197-8-3-2022-29-AS-DPEA-CQ8VX2-20230324164848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608197
Report Date: 08/03/2022
Date Signed: 08/03/2022 03:56:34 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
07/26/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20220726161113

FACILITY NAME:	WALNUT GARDENS		FACILITY NUMBER:	197608197
ADMINISTRATOR:	TAMARA BOODNERO		FACILITY TYPE:	740
ADDRESS:	5128 CEDROS AVENUE		TELEPHONE:	(818) 855-1459
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	6	CENSUS: 6	DATE:	08/03/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Maia Budnero		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are not wearing face coverings.

INVESTIGATION FINDINGS:

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On 08/03/2022, Licensing program Analyst Sandra Urena conducted an unannounced visit to investigate the allegations named above. LPA Urena arrived at the facility at 10:30 a.m., met with staff, and explained the reason for the visit. LPA was informed that that Administrator, Tamara Boodnero was on vacation. Staff contacted Maia Budnero, facility representative. At 11:40 a.m., the LPA met with the facility representative, and explained the reason for the visit.

At 11:00 a.m., the LPA, and the staff conducted a brief tour of the facility. The LPA, and the staff observed three out of three staff not wearing a face covering (mask), while in close proximity of the residents in care. The LPA advised the staff that the facility must follow all CDC guidelines and CDSS regulations.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220726161113

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 GARDENS	FACILITY NUMBER: 197608197
	VISIT DATE: 08/03/2022

NARRATIVE

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Regarding the allegation ‘Staff are not wearing face coverings. It is the concern of the reporting party that staff are not wearing face coverings/masks, and that the facility has not been safeguarding residents by not practicing proper infection control. LPA Urena conducted brief interviews with two staff at 10:45 a.m., and 10:50 a.m., and asked about their use of face coverings/masks, and if any outside agencies have observed staff not wearing masks. Staff stated that yes a recent outside agency had visited the facility and advised them about wearing face coverings.

Based on the LPA’s observation, and interviews with staff, there is sufficient evidence to support the allegation ‘Facility staff does not wear a mask.’ Therefore, this allegation is deemed 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 was conducted with facility representative, a copy of the report, and Appeal Rights were issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220726161113

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 GARDENS	FACILITY NUMBER: 197608197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/12/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee has agreed to do the following: 1. Submit staff training sign in sheet and supporting documentation- Infection Control Practices PIN 21-38-ASC regarding masks wearing in the facility to LPA by 08/12/2022.
	8 9 10 11 12 13 14	Based on observation, and interviews conducted, the Licensee did not comply with the section cited above, as three out of three staff were not wearing face coverings while providing care and supervision to residents in care, 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: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC9099 (FAS) - (06/04)

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