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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 08/04/2021
Date Signed: 08/04/2021 02:08:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:LACY BERRYFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 55DATE:
08/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lacy Berry, Administrator TIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Sabrina Calzada and Kevin Mknelly arrived unannounced to attend a meeting between the Ombudsman's office and the facility regarding recent follow up concerns with the current resident council situation. LPA's met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, confirmed with the facility there are currently no positive Covid-19 diagnoses and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

At the conclusion of the meeting, LPA's discussed (2) recent incidences occurring at the facility that were discussed with the Administrator on 7/21/2021 that resulted in the issuance of (3) citations in this report, as follows:

1) On 7/21/2021, staff (S2), Med-Tech, requested that staff (S1), receptionist, assist her in administering 6:00 am medications to resident (R1). Interviews with staff (S1 and S2) and resident (R1) all confirmed that staff (S1), who is not trained in medication administration, administered medication to resident (R1) on the morning of 7/21/2021. Administrator stated she was not aware of this incident but that staff (S1) is trained as a caregiver but has not had training in administering medications. Review of Medication Administration Record (MAR) for July 2021 for resident (R1) documents that medication Carbidopa-Levodopa 25-100 mg was issued to resident (R1) at 6:00 am on 7/21/2021 by staff (S2).

2) On 7/16/2021, resident (R2) was found, at approximately 6:45 -7:00 am, outside in the facility back parking lot, sitting in the front seat of an unlocked and unmarked facility van by staff (S3, S4 and S5) . LPA's inspected the unmarked van on 8/4/2021 and found the doors to be unlocked at approximately 11:00 am.
cont on 809C...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
VISIT DATE: 08/04/2021
NARRATIVE
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Interview with staff (S3) who has worked at the facility for (5) years approximately indicated that resident has tried to exit the facility before on her own. Additional interviews confirmed that any exit door opened without the use of the key pad will activate the alarm; however, interviews also indicated that the alarm was not heard when resident (R2) exited at approximately 6:20 am, when resident was found to be missing, as reported on the LIC624.

Facility completed an Unusual Incident/Injury Report (LIC624) for the incident on 7/16/2021 and it was emailed to the department on 7/22/2021 when requested.

LIC624 stated that resident (R2) was observed to not be in her room when staff was making her rounds at 6:20 am but after a brief search resident was found in the back parking lot. LIC624 indicates that a care conference would be scheduled with resident's (R2) family to discuss the incident and Administrator stated to LPA on 7/21/2021 that she would follow up with resident's family regarding relocating resident to a related facility with a memory care program. Administrator indicated on 8/4/2021 that a recent care conference was conducted with resident's (R2) family to begin the process of relocating resident to a higher level of care.

Most recent care plan was also reviewed on 8/4/2021 and it is dated as 7/24/2020. Care plan notes that resident has Dementia but does not mention any wandering tendencies.

Physician's report for resident (R2), dated 10/5/2018, notes that resident has a diagnosis of Dementia, is confused/disoriented and is not able to leave the facility unassisted. Physician's report provided to the department today had not been updated within the last 12 months. (deficiency issued in 809D)

Based on information obtained from interviews and document review, the following (3) citations are issued per Title 22 Regulations, Division 6, Chapter 8. See 809D pages for citations issued.

Exit interview. Copy of report and appeal rights provided.



SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/05/2021
Section Cited

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§1569.69 Employees assisting residents with self-administration of medication; training requirements (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:
(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
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Based on interviews conducted, the Licensee did not ensure that staff (S1) met all of the training requirements prior to administering scheduled medication (Carbidopa-Levodopa 25-100 mg) on 7/21/2021, at approximately 6:00 am, to resident (R1), which posed an immediate health and safety risk to resident in care.
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Request Denied
Type A
08/05/2021
Section Cited

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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by:
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R2) was not able to leave the building unassisted on 7/16/2021 between 5:20 am- 6:20 am, which posed an immediate health and safety risk to resident in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2021
Section Cited

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
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Based on documentation reviewed, the Licensee did not ensure that resident (R2) had an annual medical assessment on file that was completed within the last 12 months, which posed a potential health and safety risk to resident in care. Physician's report indicates medical exam was completed for resident (R2) on 10/5/2018.
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Type B
08/18/2021
Section Cited

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There is not a second citation issued on this page.

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4