342700186-10-19-2021-27-AS-MSEY-CBNTLZ-20220215135021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 10/19/2021
Date Signed: 10/19/2021 06:00:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/06/2021 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210106155437

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: 59	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lacy Berry, Administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility is unsanitary
Residents' bathing needs are not being met.
Facility staff are not properly supervising residents.
Staff left residents on soiled bedding

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the investigation into a complaint recerived on 1/6/2021 and to deliver findings on the above allegations. LPA met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before before entering the facility and wore the following Personal Protective Equipment (PPE): surgical mask.

During the course of the investigation, LPA reviewed documentation including, but not limited to, Medication Administration Record (MAR) for Dec 2020 and Jan 2021, photos (2) submitted to the department on 1/6/2021, (3) Death reports (LIC624A) from 12/30/2020, and staffing schedule for January 2021 and shower documentation. LPA interviewed Administrator, (7) staff, (5) residents, a family member of resident (R1) and attempted to interview (2) additional staff who were not available for an interview.

The results of the investigation are as follows:

cont on 9099-C(1)...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 27-AS-20210106155437

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2021

NARRATIVE

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9099-C (1)..Allegation: Facility is unsanitary. Allegation is floors are dirty and messes are left on the tables. Due to the department not conducting regular in-person inspections on/around January 2021, due to Covid-19 precautionary measures in place, LPA was unable to inspect the facility for cleanliness on 1/12/2021, when the complaint investigation was opened. On 5/20/2021, LPA observed different areas of the facility in person, including resident rooms, for cleanliness. LPA observed the entrance area to smell of cleaner/disinfectant, the living and front rooms with couches to appear clean and clutter free, the activities room and dining room to have clean floors and tables, and hallway carpets and carpet in residents’ rooms to appear clean and to have been recently vacuumed. On 6/23/2021, 7/21/2021, 9/10/2021 and on 10/14/2021, LPA observed the floors to be clean, recently vacuumed and the tables in the common areas to be clean and without messes.

Administrator stated to LPA on 1/12/2021 that the facility did not currently have a maintenance staff person and the Maintenance Director splits his time at another facility and that housekeeping staff was doing the cleaning of the facility. Staff interview conducted in May 2021 revealed that for approximately eleven (11) months there was only (1) housekeeper until a second one was hired on/around April 2021. One staff stated that on/around January 2021, the floors and tables were dirty as residents were eating their meals and drinking coffee in their rooms through the end of February 2021 when they started eating in the dining room again and staff would find "yesterday's coffee" in their rooms. Another staff stated that everyone gets messy and sometimes the floor gets dirty but professional carpet cleaning is done in all resident rooms and in the lobby and that floors and tables are the first thing cleaned on the shift. A third staff stated that housekeepers do a good job in keeping the floors and tables clean, and if drinks and/or food are spilled on the tables in the common areas, it is cleaned promptly.

Based on information received, LPA finds the above allegation to be UNSUBSTANTIATED.

Allegation: Residents' bathing needs are not being met. One resident interviewed stated that the facility "is an old building and sometimes the shower breaks- they try very hard to get the showers in twice per week as scheduled". Two additional residents stated there have not been any problems with receiving showers. A caregiver staff stated staff will fill-out a paper if the resident refuses, and if they are short staffed, they will ask the resident if they can give the shower the next day. Another staff stated on 7/21/2021 that “showers are not skipped, generally, and caregivers have to report if showers are missed”.
cont on 9099-C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 27-AS-20210106155437

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2021

NARRATIVE

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9099-C(2)...Administrator stated that caregivers should note if a resident refuses the shower or if it is missed; if it is missed, it will be given the following morning and staff are diligent about ensuring showers are given twice weekly, as scheduled.

LPA reviewed “Shower Refusal Documentation” requested on 1/12/2021 and was provided with documentation that (1) resident refused a shower on 12/29/2020, (2) residents on 12/31/2021, (1) resident on 1/12/2021 and (2) residents on 1/13/2021. There was no resident that had more than one shower refusal on the days reviewed. LPA and Resident Care Coordinator reviewed the weekly shower schedule and documentation completed following a shower being given on 10/18/2021. Of the (6) showers scheduled, documentation had been made by staff for (2) showers and LPA was advised that (1) resident received a shower from hospice services. For the remaining scheduled (3) showers, (2) residents stated they were offered a shower, with (1) resident refusing and (1) resident was not able to recall if she had received a shower yesterday.

LPA finds the allegation to be UNSUBSTANTIATED.

Allegation: Facility staff are not properly supervising residents. Complaint alleges that (2) residents were found dead because nobody had checked on them and another resident was left unsupervised “just lying there”.

LPA reviewed a photo that was provided to the department showing resident (R1) to be on her knees and asleep with her head resting on her couch. LPA confirmed with (2) Med-Tech staff on 7/21/2021 and with the Administrator on 10/19/2021 that the resident in the photo provided to the department is resident (R1). One caregiver interviewed stated that there are a couple of residents that want to sleep on the couch and won't get up and there is "always someone around" to supervise residents. A Med-Tech staff confirmed they have never seen R1 sleep like that before and "no, it is not acceptable that we would leave her like that - we would put her in bed even though she liked to sleep on the couch”. Another staff stated that staff will let residents sleep and not wake them, even if they fall asleep in a chair or on the couch. A med-tech staff stated that R1 had a hard time moving around the table, so resident's daughter moved the table. Additionally, staff stated resident was "hard to turn for her age", has Dementia and has fallen asleep on the couch several times previously, as shown in the photo. Administrator stated that resident (R1) would often fall asleep in the position shown in the photo and “staff would try and wake her up and sit her back up and she would go back to laying on the couch”, stating “she loves the sofa”. Administrator indicated the large coffee table shown in the picture is not in R1’s room anymore and resident doesn’t sleep as much on the couch anymore since she is receiving hospice services and not as strong.
cont on 9099-C(3)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 27-AS-20210106155437

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2021

NARRATIVE

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90099C(3)...The department is unable to determine from the photo alone how long R1 was sleeping on the couch, as shown in the photo, to establish that there was a lack of supervision by facility staff.

Interview with one staff indicated that, on 12/31/2020, resident (R2) was discovered right away by the receptionist and her hands were still warm but was not sure who found resident (R3) whose family was with him when he died and had been with him all week. Another staff stated that both the death of R2 and R3 were “discovered right away” and resident (R4) was receiving hospice services and the nurse had recently indicated R4 had about one week to live. The same staff stated that resident R2 and R4’s room were near each others and R3’s room was also close by, and staff always knows right away if a resident passes, as with any change in condition, which are discussed at change-over meetings. LIC624’s submitted to the department note that R2 was observed to be unresponsive on 12/31/2020 at approximately 7:15 am and hospice was immediately contacted; the hospice company was immediately notified on/around 4:25 pm on 12/31/2020 for death of R3; and on 12/31/2020, R4 was observed to be unresponsive around 9:00 pm by the Shift Manager when entering resident’s room and the hospice was immediately notified.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED.

Allegation: Staff left residents on soiled bedding. Complaint alleges bedding is not changed. A resident stated on/around May 2021 that her bed linens are changed weekly and cleaning is done regularly, but since there are only (2) housekeepers, occasionally something is missed. The same resident stated, "sometimes I heard but have never observed anyone to be laying in their bed and not changed timely". One staff stated that once there were (2) housekeepers, the housekeepers began changing the sheets, whereas, previously caregivers were in charge of changing sheets. Staff confirmed that it is possible a resident might have to wait for an extended period of time when there is only (1) caregiver working. Staff gave the example of “when a caregiver starts in room 1 and the resident in room 65 needs help, then it could be (2) hours until the caregiver gets to the resident, due to the distance in the building”. Additionally, if the facility is short staffed with caregivers, showers are not given, clothes and bedding are not washed, and the bedding sometimes can’t be changed because there are no clean sheets due to not enough staff to wash them. Staff stated the first thing caregivers do on their shift is change the bedding and housekeepers will also help. Additionally, the same staff indicated that staff will check on residents frequently and knows which residents need more frequent changing.
cont on 9099-C(4)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 27-AS-20210106155437

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2021

NARRATIVE

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9099-C(4)...Another staff stated residents have been left in soiled bedding before-“it's with the heavy wetters- usually the "am" staff saying they are too wet" and asserted that the NOC shift needs to pay more attention to the heavy wetters. Administrator stated that residents are not left in soiled bedding.

Based on information received, LPA finds the above allegation to be UNSUBSTANTIATED.

Based on information obtained during the investigation, LPA finds the above (4) allegations 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) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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