342700186-10-1-2020-27-AS-LKLN-BUTRCF-20201028125416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 09/23/2020
Date Signed: 10/01/2020 03:00:30 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
06/19/2020 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200619115544

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: 55	DATE:	09/23/2020
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Lacy Berry, Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Staff are not appropriately communicating with resident.
Staff did not assist resident with care needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada contacted Lacy Berry Administrator, by phone to deliver findings to a complaint the department received on 6/19/2020. Findings are being delivered via phone due to current Covid-19 pre-cautionary measures. LPA explained purpose of call.

During the course of the investigation, LPA interviewed Administrator, (3) Med-Tech/Caregiving staff and resident (R1). LPA also reviewed facility pendant response times for resident for the month of August 2020.

The results of the investigation are as follows:

Allegation: Staff are not appropriately communicating with resident.

Complaint alleges that staff will enter and exit resident’s room unannounced and resident is unaware due to resident being visually impaired. In addition, it is alleged that staff is taking drinks from resident’s personal inventory in resident’s refrigerator. Resident stated that the last time a drink was missing from resident's room was on 6/24/20.

Interviews with (2) staff indicated that neither staff is aware nor has seen any other staff taking drinks from resident’s personal refrigerator, and (1) staff stated that resident is “counting her drinks all of the time”. A third staff interviewed indicated that on one occasion, resident asked about one drink disappearing from her room.

cont on 9099C(1)...

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: 09/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020

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-20200619115544

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: 09/23/2020

NARRATIVE

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9099C(1)...The same staff stated that the drink resident was asking about was in the corner of the small freezer section of the personal refrigerator and resident didn’t see it. The same third staff indicated that he is not aware of any staff or residents taking resident’s drinks.

Administrator stated on 6/26/20 that she had a recent meeting with resident and moved resident’s items to a place resident wanted them to in her room and posted signage to not touch resident’s items. Administrator added that she does not believe anyone is taking resident’s drinks as lots of residents have their own snacks and drinks in their rooms.

All (3) staff interviewed and Administrator stated that staff will always knock before entering and announce who they are and also close the door, as resident always requests, upon leaving resident’s room.

Based on information obtained, LPA finds the above 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.

Allegation: Staff did not assist resident with care needs.

Complaint alleges that on/around 6/27/20 and on other occasions, during the “pm” shift, resident requested assistance from staff in choosing an outfit and in reading mail, but no staff came to assist resident. Interview with one “pm” staff revealed that staff forgot once or twice to assist resident after resident pushed the pendant but staff went late to assist resident. The same staff indicated that resident will call reception again or push their pendant again if no staff responds timely. Another staff who works on the “pm” shift stated that they will help resident with opening and reading their mail, as requested by resident, and will also request that the Resident Care Coordinator assist resident with reading mail. cont on 9099C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20200619115544

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: 09/23/2020

NARRATIVE

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Administrator stated that resident would call the front desk as the main method to call staff, and staff will go assist resident with choosing their clothing. A third staff who works “am” shift indicated resident will call for assistance with their hair only during the morning hours and resident is assisted by them.

LPA reviewed resident pendant response times for August 2020 and noted that resident called staff for assistance one time, on 8/11/2020 @ 9:02 am and received assistance from staff @ 9:19 am. Resident was out of the facility for the remainder of the month. Pendant response times were not available for LPA's review prior to August 2020.

Based on information obtained, LPA finds the above 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.

Based on information obtained during the investigation, there were no deficiencies found per Title 22 Regulations, Division 6, Chapter 8.

Exit interview. Copy of report provided to Administrator by email. Administrator agrees to print and sign (2) copies of the report and return (1) copy to CCLD by end of day, 9/23/20.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020

LIC9099 (FAS) - (06/04)

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