342700186-4-1-2022-25-AS-MSEY-CD7TYL-20220405150856

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 04/01/2022
Date Signed: 04/01/2022 05:50:48 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
07/21/2021 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20210721115341

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: 66	DATE:	04/01/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Lacy Berry		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not responding to residents alerts timely
Staff does not follow the disaster plan as required

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on to deliver complaint findings. LPA met with and explained the purpose of the visit. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

The department reviewed client/resident records and conducted extensive interviews.
The department finds that the allegations cited above are substantiated.

During the course of the investigation, LPA Sabrina Calzada requested the facility’s call alarm logs and was told by the Administrator that they did not have access to them. LPA Kevin Mknelly repeated the request in March 2022 and was provided call logs for June- July 2021.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

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 25-AS-20210721115341

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: 04/01/2022

NARRATIVE

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LPA Mknelly review sample of call logs for June 1-4, 2021 and July 1-4/ 2021 found the following: June 1- 4 had a total of 52 calls recorded with a response time of greater than 20 minutes; July 1- 4 had a total of 54 calls recorded with a response time of greater than 20 minutes: Call log for 7/13/21 for R4 found that at 5:27:18 am, the resident’s call was made. The response time is recorded as 61.9 minutes. An indent report submitted on 7/17/21 of 7/13/21 notes that staff responded to R4 at approximately 6:30 am for shortness of breath secondary to respiratory condition which required emergency response and resulted in hospitalization.

On 10/14/21, LPA Calzada interviewed three (3) residents, 2 of 3 reported wait times in excess of 1 hour. While interviewing R 2 , R2 noted that they had been waiting 20 minutes for incontinence care when LPA arrived.

On 3/30/22, LPA Mknelly interviewed three (3) residents with recorded response times June 1-4/ 2021.
Two (2) of the three (3) residents stated that long wait times have happened and continue to happen.
A fourth resident was interviewed on 3/30/21 by LPA Mknelly regarding a resident report that they also experience long wait times. In the interview with R 3 , R3 stated that they regularly experience long wait times, they have reported that their button does not work. LPA and R3 tested the call button which was not in reach if R3 when LPA arrived. The button was pressed at 1:55 pm. Red light indicated a call was sent. No staff response at 2:40 pm. LPA spoke with a maintenance manager, Patrick Guevara, who acknowledged that the button should be tied to R3‘s bed and that he has checked the button several times and has ensured to works. LPA then went to the reception area where calls are monitored. Receptionist, Aylin Mendez, should LPA that no call was recorded for R 3. Receptionist recorded a repair request.
Therefore, this allegation is substantiated.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210721115341

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: 04/01/2022

NARRATIVE

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**This page contains Amended language**
On January 29, 2021, the facility submitted an incident report for a power outage on January 27, 2021 at 2:00 am.
Facility’s emergency and disaster plan states that “… Disaster Leader… will ensure residents are kept comfortable… will continuously communicate with licensing representatives…”. Reporting requirements are that the facility notify Community Care Licensing of a catastrophe within 24 hours.
R1 reported that they informed their family/ representative of the outage the following day. Family representatives agreed with the statement.
AccuWeather.com recorded the temperatures for 1/27/21 as 42- 52 degrees F., 1/28/21 as 45- 50 degrees F.
Interviews found that the facility did not supply space heaters to be run by the facility generator until 1/28/21.
Staff placed blankets on the window of R1’s room to reduce drafts.
Residents reported cold foods were supplied to residents. Administrator stated facility did not lose capability to serve hot food and drinks.
Therefore, facility failed to follow the disaster plan as required by not properly reporting to CCL, a resident family and ensuring residents were kept comfortable. Administrator stated to LPA Mknelly during this review that resident families were notified and residents kept comfortable,

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.

Report reviewed with Administrator. Copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210721115341

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/04/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on records and statements showing insufficient staffing	1 2 3 4 5 6 7	Licensee will monitor responding to log records and submit a detailed plan to insure staffing to meet the needs of residents. POC due monday 4/4/22
	8 9 10 11 12 13 14	to meet the needs of residents. On 7/13/21 this posed an immediate risk to Resident health.	8 9 10 11 12 13 14
Type B 04/22/2022 Section Cited CCR 87211(a)	1 2 3 4 5 6 7	Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports ...(2) Occurrences, such as ..., catastrophes ... which threaten the welfare, safety or health of residents...within 24 hours ... This requirement was not met based	1 2 3 4 5 6 7	Licensee will update their Emergency Plan to specify reporting requirements procedures. to CCL by the POC date of 4/22/22.
	8 9 10 11 12 13 14	on records and statemets that the January 27/2021 power outage was not reported as required. This posed a potential risk to residents.	8 9 10 11 12 13 14

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: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
07/21/2021 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20210721115341

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: 66	DATE:	04/01/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Lacy Berry		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident oxygen services were not met while in care
Residents are left unattended during the evening hours
Staff is preventing residents from having access to personal funds
Staff does not communicate effectively

INVESTIGATION FINDINGS:

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On date) at (time AM/PM), Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with clinical staff. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms .Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened with temperature at the facility.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

Statements by staff indicated that during the power outage Jan. 27-29, 2021, R1 was provided assistance with bottled oxygen in a timely manner. R1 was inconsistent in her statements to family and LPAs.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 25-AS-20210721115341

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: 04/01/2022

NARRATIVE

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Records reviews and statements indicated that staff were scheduled during the overnight hours. While there is a substantiated allegation for staff not always responding timely to resident calls, evidence did not indicate that the facility was unattended.
The facility maintains cash resources for some residents. During the time of this complaint, it is acknowledged that when the Administrator was not present, resident funds were not available. However, LPA did not find an instance when residents requested funds and were denied access.
The allegation that staff does not effectively communicate is undetermined. However, it is found that facility staff did not properly report the power outage of 1/27/21 to all family members and CCL.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means 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.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC9099 (FAS) - (06/04)

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