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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 06/15/2022
Date Signed: 06/15/2022 01:12:38 PM

Unsubstantiated


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
04/04/2022 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220404130057
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: 64DATE:
06/15/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lacy BerryTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident's requests for assistance are not responded to.
Resident's clothing is not being laundered.
Resident's showering needs not being met.
Resident's administration of medications is being mismanaged.
INVESTIGATION FINDINGS:
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On 6/15/22, 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 interviews. LPA interviewed R1 again today 6/15/22
LPA is unable to find and or meet the preponderance, per policy.

R1 maintained that they are not filing a complaint, they only wish to have improved communication. R1 requests to have their Service plan updated with details that would better assist her to manage
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
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 2
Control Number 25-AS-20220404130057
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: 06/15/2022
NARRATIVE
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information and expectations regarding her medications, pain medications, shower and laundry times and when best to use her call button vs. phone to the front desk. R1 also requests assistance with a information management system.

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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
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