342700186-9-8-2020-27-AS-MSEY-BTANSE-20200909104300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 09/08/2020
Date Signed: 09/08/2020 02:37:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2020 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200608123041

FACILITY NAME:	WALNUT HOUSE		FACILITY NUMBER:	342700186
ADMINISTRATOR:	LACY BERRY		FACILITY TYPE:	740
ADDRESS:	3401 WALNUT AVE		TELEPHONE:	(916) 483-6612
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	110	CENSUS: 52	DATE:	09/08/2020
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Lacy Berry, Administrator		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Residents room has mold

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada contacted Administrator, Lacy Berry, by phone on 9/8/20 to deliver findings to a complaint the department received on 6/8/2020. Findings are being delivered via phone due to current Covid pre-cautionary measures. LPA explained purpose of call.

During the course of the investigation, LPA interviewed Administrator, Maintenance staff, (3) Med-Tech/Caregiving staff and resident (R1). LPA reviewed photo documentation of resident's room taken on/around 9/4/20.

The results of the investigation are as follows:

Resident stated on 6/17/2020 that the carpet was dry but there was still a smell in the room. Administrator stated on 6/17/20 that she and the Resident Care Coordinator checked the carpet in resident's room on that day and neither of them saw or smelled any signs of mold; however, resident indicated to Administrator that resident could still smell a slight odor from the water getting on the carpet. Administrator stated she offered for housekeeping to promptly vacuum resident's room using carpet deodorizer, which resident agreed to. Interview with maintenance staff confirmed that on the Monday following the flood, 5/25/20, the carpet was dry, but there was still a smell in the room from the carpet being wet. One staff interviewed confirmed that maintenance staff asked that staff on Monday, 5/25/20 why the room still smelled. That same staff stated the odor was due to resident not allowing the windows to be left open. Maintenance staff stated the carpet in resident's room was shampooed twice in both the main area and closet area of resident's room and
cont on 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

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 27-AS-20200608123041

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WALNUT HOUSE	FACILITY NUMBER: 342700186
	VISIT DATE: 09/08/2020

NARRATIVE

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windows were opened for two days, excluding nights, to allow for the carpet to completely dry. Maintenance staff stated that the wet carpet smell was gone three days later, or by Thursday, 5/28/20, and there was no odor as of 6/26/20, when the interview was conducted. Maintenance staff asserted during the same interview that there is currently no mold in resident's room and the carpet does not need to be replaced. Another staff also stated that it was not certain if there was any mold underneath the carpet but was certain that there is not any mold above the carpet. A third staff stated they were one of the first staff to notice the flooding and immediately placed towels down to begin to absorb the water and noted that fans were used the next day to soak up additional water. A fourth staff interviewed did not recall the flooding nor seeing any mold or smelling any trapped moisture in resident's room.

LPA reviewed photos taken of resident's room on/around September 2020 and did not observe any mold on the carpet. Interviews concluded there were not any documented work orders on record relating to the flooding and shampooing of resident's room. Administrator stated if a maintenance issue is reported to the front desk, it would have been written in the maintenance book, but if it was observed from walking by the room, it may have not been documented. LPA was not able to observe resident's room in person during the investigation due to Covid 19 pre-cautionary measures in effect.

Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with administrator. Copy of report provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

LIC9099 (FAS) - (06/04)

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