342700186-12-9-2021-25-AS-KMKY-C9JRBC-20211209115230

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 12/09/2021
Date Signed: 12/09/2021 11:52:39 AM

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 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: 63	DATE:	12/09/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lacy Berry		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/9/21, Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced to conduct a case management inspection to follow up on recent concerns brought to their attention. LPA's Mknelly and Calzada and LTCO met with Lacy Berry, Administrator on 12/2/21 regarding and incident report of R1 leaving the building unassisted. LPA informed Administrator Berry that today's visit is a follow-up to that incident. and explained purpose of inspection. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm if there are any positive Covid-19 diagnoses, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19. Additionally, LPA's were 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: N95 or surgical Mask. The incident report submitted 11/19/21 stated that "around dinner time", R1 was observed in the community and refused dinner when cued. Statement by administrator that around 5:45pm when the caregiver brought the resident's tray to him, R1 was not in known locations and staff conducted a search of the building and grounds. Med tech, S1, stated to LPA that

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: 12/09/2021

NARRATIVE

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she located R1 when he was observed to be entering the building by the front door. The door was unlocked and the daytime door alarm sounded. S1 stated that she had not heard the door alarm when R1 had exited the building.

LPA conducted an inspection of the facility's door alarms. The front door exit/entrance is the only door to have a daytime alarm that is only loud enough for the immediate area and a night time alarm that is like all others- it is louder and continuous until reset by staff with a code.

At the time that R1 left the building, there were two caregivers and a med tech who were all occupied with resident care. The receptionist had left for the day.

Title 22 regulation 87303 Maintenance and Operation (i)(1)(B) requires that (i) facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as Care staff did not hear the front door alarm when R1 exited the building.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview with Administrator. Report and appeal right provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

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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: 12/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/10/2021 Section Cited	1 2 3 4 5 6 7	Maintenance and Operation (i) facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
	8 9 10 11 12 13 14	This requirement was not met based on records and interviews which found that on 11/18/21, R1 left the building unassisted and staff did not hear the front door alarm when R1 exited the building. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14	To be cleared by POC visit.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

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