306000961-1-22-2026-22-AS-APAO-DQT9JZ-20260129222535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000961
Report Date: 01/22/2026
Date Signed: 01/22/2026 04:18:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/01/2021 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210201111047

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:	334	CENSUS: 206	DATE:	01/22/2026
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Deborah Infield		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to complete the investigation and deliver findings on the complaint allegation listed above. LPA explained the purpose of the visit upon entry. The complaint investigation consisted of interviews and document review.

Regarding the allegation: Resident sustained multiple falls while in care

During the investigation, interviews were conducted with 3 individuals including facility staff and a family member of Resident 1 (R1). Documents were reviewed and revealed that R1 did sustain falls while in care. According to documents, falls occurred November 16, 2019, August 14, 2020, and January 26, 2021. After the fall in January 2021, R1 was sent to skilled nursing for physical therapy before returning to the facility. Additional document review reveal, R1 was put on hospice July 13, 2021, and eventually passed away at the facility with their family at bedside.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

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-20210201111047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: WALNUT VILLAGE	FACILITY NUMBER: 306000961
	VISIT DATE: 01/22/2026

NARRATIVE

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W1 was interviewed regarding the January 26, 2021, fall and W1 confirmed a fall did occur; however, W1 stated they were pleased with the care provided at the facility.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegation is deemed unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

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