306000961-7-28-2020-22-AS-AORZ-BRYNUL-20200729104629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000961
Report Date: 07/28/2020
Date Signed: 07/28/2020 04:21:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2020 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200508145412

FACILITY NAME:	WALNUT VILLAGE		FACILITY NUMBER:	306000961
ADMINISTRATOR:	NADINE A. ROISMAN		FACILITY TYPE:	741
ADDRESS:	891 WALNUT STREET		TELEPHONE:	(714) 776-7150
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	300	CENSUS: 209	DATE:	07/28/2020
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Nadine Roisman, Executive Director		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff failed to follow resident's doctor's orders
Resident had unexplained bruising
Staff failed to properly manage resident's medications
Resident was illegally evicted
Staff failed to inform family of change in resident's medical condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson contacted the facility via telephone to conclude a complaint investigation via telephone due to COVID-19 and for precautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations and investigation with Executive Director (ED) Nadine Roisman. During the investigation, LPA reviewed records, interviewed staff, residents and a witness. Regarding the allegation "Staff failed to follow resident's doctor's orders", the investigation revealed the following: Records reviewed indicated on 4/10/2020, Resident #1's (R1) physician ordered thickener to be added to any thin liquid. The facility received the order on 4/13/2020 and instituted the order providing R1 with containers of pre-thickened water and juice until their departure of the facility on 4/22/2020. It should also be noted that on or about 4/16/2020, R1's responsible party instructed staff to stop providing thickened liquids, but records indicate these instructions were refuted by staff so as to follow the physician's order. Regarding the allegation "Resident had unexplained bruising", the investigation revealed the following: Records reviewed indicated R1 was noted to have bruises to the left thigh on 4/18/2020. However, records also revealed R1 fell on their left side on 4/17/2020. Bruising to R1's left thigh was discovered and documented on 4/17/2020. (CONTINUED ON LIC 9099 C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

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 4

Control Number 22-AS-20200508145412

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WALNUT VILLAGE	FACILITY NUMBER: 306000961
	VISIT DATE: 07/28/2020

NARRATIVE

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(CONTINUED FROM 9099)
Regarding the allegation "Staff failed to properly manage resident's medications", the investigation revealed the following: Interviews conducted with staff, R1 as well as R1's responsible party revealed R1 was responsible for administering their own medications and did not require assistance from staff nor was R1 paying for medication administration services. Regarding the allegation "Resident was illegally evicted", the investigation revealed the following: Interviews with staff, R1's responsible party and family revealed no written eviction notice was ever provided to R1 or their responsible party nor was a verbal eviction notice given. Record review indicated R1's responsible party was informed that R1 required a higher level of care and/or a private duty nurse. Record review also indicated R1's responsible party was allowed time to discuss these options with another family member. No evidence was discovered that would have indicated R1 was required to vacate the facility premises involuntarily. Regarding the allegation " Staff failed to inform family of change in resident's medical condition", the investigation revealed the following: Record review revealed ten (10) exchanges of information concerning R1's condition between the facility and R1's responsible party and family between 3/5/2020 and 4/22/2020. This includes a Health and Wellness Review on 3/24/2020 which was signed by R1's responsible party.
This agency has investigated the complaint alleging "Staff failed to follow resident's doctor's orders", "Resident had unexplained bruising", "Staff failed to properly manage resident's medications", "Resident was illegally evicted", and "Staff failed to inform family of change in resident's medical condition". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with ED Roisman via telephone and a copy of this report along with LIC 811- Confidential Names List was provided via email and an electronic read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2020 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200508145412

FACILITY NAME:	WALNUT VILLAGE		FACILITY NUMBER:	306000961
ADMINISTRATOR:	NADINE A. ROISMAN		FACILITY TYPE:	741
ADDRESS:	891 WALNUT STREET		TELEPHONE:	(714) 776-7150
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	300	CENSUS: 209	DATE:	07/28/2020
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Nadine Roisman, Executive Director		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

1
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3
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5
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9

Staff failed to assess resident for injuries after falls
Staff failed to treat resident with dignity and respect

INVESTIGATION FINDINGS:

1
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3
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5
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13

Licensing Program Analyst (LPA) Tricia Danielson contacted the facility via telephone to conclude a complaint investigation via telephone due to COVID-19 and for precautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations and investigation with Executive Director (ED) Nadine Roisman. During the investigation, LPA reviewed records, interviewed staff, residents and a witness. Regarding the allegation "Staff failed to assess resident for injuries after falls", the investigation revealed the following: Record review indicated R1 was assessed for injuries after a fall which took place on 4/17/2020. Interview with staff indicated an assessment was done of R1 following the 4/17/2020 fall. However, interview with R1 indicated no assessment was completed and that R1 was only assisted to thier feet. Regarding the allegation "Staff failed to treat resident with dignity and respect", the investigation revealed the following: Interview with R1 indicated they felt rushed during times of staff assistance particularly during mealtimes. Interviews with staff indicated R1 was not rushed and was unable to be rushed due to their frailty and ritualistic manner in which tasks were completed. Although the allegations may have happened or are
(CONTINUED ON LIC 9099 C) *This is an amended report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20200508145412

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WALNUT VILLAGE	FACILITY NUMBER: 306000961
	VISIT DATE: 07/28/2020

NARRATIVE

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(CONTINUED FROM LIC 9099 A)
valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
An exit interview was conducted with ED Roisman via telephone and a copy of this report along with LIC 811- Confidential Names List and LIC 9102- Technical Advisory Note was provided via email and an electronic read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 4