306000961-3-15-2023-22-AS-SSAS-CPZQCN-20230317120323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000961
Report Date: 03/15/2023
Date Signed: 03/15/2023 03:49:10 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, 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
03/07/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230307094722

FACILITY NAME:	WALNUT VILLAGE		FACILITY NUMBER:	306000961
ADMINISTRATOR:	DEBORAH INFIELD		FACILITY TYPE:	741
ADDRESS:	891 WALNUT STREET		TELEPHONE:	(714) 776-7150
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	300	CENSUS: 191	DATE:	03/15/2023
		UNANNOUNCED	TIME BEGAN:	03:08 PM
MET WITH:	Debbie Infield		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility did not complete a reppraisal prior to admission to the memory care unit.
Facility admitted residents to the memory care unit without prior consent from the residents and/or their authorized representatives.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to deliver the findings into the above allegations. LPA met with Executive Director (ED) Debbie Infield and stated the purpose of the visit.
During the course of the investigation, LPA obtained and reviewed copies of records pertinent to Resident 1 (R1) to Resident 4 (R4). Interviews were conducted with (3) residents, Health Services Director (HSD) Pamela Lowe, and ED Infield. The investigation revealed the following: It was alleged that the facility did not complete a reappraisal prior to admission to the Memory Care Unit (MCU). It was reported that the reappraisals were not completed for R1 and R2. Regarding R1, the reappraisal was completed on January 30, 2023 and signed and dated January 31, 2023 after R1 was admitted to the MCU on January 4, 2023. R2 was admitted to the MCU on March 6, 2023 and a reappraisal was conducted on February 6, 2023. Per Title 22 Regulation, 87457 Pre-Admission Appraisal, facility did not complete an appraisal for R1 prior to admission, therefore the preponderance has been met.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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 22-AS-20230307094722

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: 03/15/2023

NARRATIVE

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It was alleged that the facility admitted residents to the memory care unit without prior consent from the residents and/or their authorized representatives. It was reported that R1 and R2 were residing in the MCU without consent. Regarding R1, LPA confirmed per review of the Interdisciplinary Notes that the conservator of R1 verbally agreed to the terms of the residency on January 4, 2023. However, R1 was noted to be at the MCU for six days prior to the verbal agreement on the following days: December 28-29, 2022, December 31, 2022, and January 1-3, 2023. In addition, R1’s conservator provided the facility staff a handwritten note on January 1, 2023 indicating that the transfer requiring prior consent. R1 continued to be placed at the memory care on 01/01-03/2023 following the conservator’s official written request as indicated on the Interdisciplinary Notes. Regarding R2, the Advanced Health Care Directive appoints two out of three conservators to make healthcare decisions. The Interdisciplinary Notes revealed that two out of three conservators verbally agreed to the terms of the residency on February 20, 2023 and R2 was admitted on March 6, 2023. Interviews conducted revealed that three out of three individuals indicated that the resident was not admitted to the MCU prior to their consent. Per Title 22 Regulation, 87457 Pre-Admission Appraisal, facility admitted R1 prior to the agreed admission date, therefore the preponderance has been met.

Based on the observations, interviews, and the records reviewed, the above allegations are deemed SUBSTANTIATED. Deficiencies are being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See LIC9099D.

An exit interview was conducted with Executive Director Debbie Infield, and a copy of this report along with the LIC9099C, LIC811, LIC9099D, and the appeal rights were provided during this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 22-AS-20230307094722

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/22/2023 Section Cited CCR 87457(c)	1 2 3 4 5 6 7	87457 Pre-Admission-General (c) “Prior to admission a determination of the prospective resident’s suitability for admission… shall include an appraisal of his/her individual service needs…” This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to review Title 22 Regulation 87457 and to submit an Acknowledgement of Understanding in writing to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review, the reappraisal was completed, signed, and dated after R1 was admitted to the memory care which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type B 03/22/2023 Section Cited CCR 87457(b)	1 2 3 4 5 6 7	87547 Pre-Admission Appraisal- General (b) No person shall be admitted without his/her consent and agreement, or that of his/her responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to review Title 22 Regulation 87457 and to submit an Acknowledgement of Understanding in writing to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review and interviews, R1 was admitted to the memory care unit for 6 days prior to the consent and verbal agreement made by R1’s POA on 01/04/2023.	8 9 10 11 12 13 14

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC9099 (FAS) - (06/04)

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