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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 02/10/2022
Date Signed: 02/14/2022 03:54:15 PM

Substantiated


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 Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210106155437
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: 62DATE:
02/10/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lacy BerryTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Residents' toileting needs not met
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Mknelly arrived unannounced to deliver complaint findings to the above allegations for a complaint received on 1/6/2021. 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 he applied hand sanitizer before entering the facility and wore the following Personal Protective Equipment (PPE): N-95 mask.


During the course of the investigation, the Department reviewed documentation including, but not limited to, Medication Administration Record (MAR) for (3) residents for Dec 2020 and/or Jan 2021, photos (2) submitted to the Department on 1/6/2021, staffing schedule for January 2021, Night Activity Reports, and other documentation. The Department interviewed the Administrator, (7) staff, (7) residents, a family member of resident (R1) and attempted to interview (2) additional staff who were not available for an interview.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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 8
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: 02/10/2022
NARRATIVE
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The results of the investigation are as follows:

Complaint alleges that residents are defecating on their beds and are made to lay in their own feces, and that the bedding is not being changed.

Interviews were conducted with residents and staff from May- September 2021.
A resident who has incontinence was interviewed in May 2021 stated, "at night, is the worse response time".

A housekeeper stated in May 2021 that housekeeping staff has been changing resident sheets, and If there is only (1) caregiver on shift, and she starts in room 1, then it could be (2) hours until the caregiver gets to the resident in room 65 due to the distance in the building. A Med- Tech stated in July 2021, when asked about residents being left in soiled bedding, “Yes, it has happened before -it's with the heavy wetter’s- usually the "am" saying they are too wet" and added that “NOC shift needs to pay more attention to the heavy wetter’s”. A caregiver stated in June 2021 that residents are checked every 2 hours and staff checks on incontinent residents more often, indicating that about 50% of residents are incontinent and they are also checked on when they press the button for assistance. This caregiver stated she feels staff are "pretty good about changing". during the "am" and 'pm" but is "not sure about the NOC" shift and stated sometimes when she arrives at 6:30 am, she sees that there is one resident that could have been seen twice during the night.

Administrator stated in June 2021 that residents are not left in soiled bedding and staff completes a "Night Activity Report" every day that shows which residents have to be changed during the night. The Administrator stated in the same interview that "all residents are changed at night- staff knows the heavy wetter’s- there are (2) to (3) residents- every hour they go”.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
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: 02/10/2022
NARRATIVE
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The “Night Activity Report” was provided for the period October 17-19, 2021 and documents hourly checks for every resident and is marked as follows: Awake (A), Bathroom (B), Diaper Change (DC), Sleeping (S) or Medicine (M). Additional documentation reviewed includes a list of residents who are incontinent, and a posted list for staff near the medication room indicating which residents (8) need to get up on the night (NOC) shift.

Of the (8) residents that need to get up on the NOC shift, (2) residents, R2 and R3, are incontinent and were not toileted during the period reviewed. Specifically, R2 was not toileted on 10/17/21 & 10/19/21- and was observed to be awake at 5 am and at 6 am on each night; however, was diapered on 10/18/21 at 4:00 am. R3 was not toileted on 10/19/2021; however, was diapered at 12:00 am and 5:00 am on 10/17/2021 and at 11 pm, 4 am and 6 am on 10/18/2021.

Additionally, resident R4, was not toileted on all three nights and resident R5 was not diapered on 10/18/2021 but was diapered on 10/17/2021 at 2:00 am and on 10/19/2021 at 2:00 am and at 6:00 am. Both R4 and R5 were noted as residents who needed to get up at night.

Based on information obtained during the investigation, the Department finds the allegation to be SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Report reviewed copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/10/2022
Section Cited
CCR
87625(b)(3)
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Managed Incontinence- b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
This requirement was not met
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Licensee will review all current incontinent resident care plans, update as needed to comply with regulation (including development and review by the appropriately skilled profession) and submit residents' incontinence care plans to CCL by the POC date 3/10/21.
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that incontinent residents (R2 and R3) were toileted regularly, including throughout the night shift, which posed a potential health and safety risk to residents in care. Additionally, department LPA’s observed incontinent odors to be found on Hall 1, (room 57), on 10/21/2021 and on 11/10/2021.
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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: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8
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 Kevin Mknelly
COMPLAINT CONTROL NUMBER: 27-AS-20210106155437

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: 62DATE:
02/10/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lacy BerryTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff not administering the resident's medications as prescribed.
Residents are not being fed.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Mknelly arrived unannounced to deliver complaint findings to the above allegations for a complaint received on 1/6/2021. 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 he applied hand sanitizer before entering the facility and wore the following Personal Protective Equipment (PPE): N-95 mask.

During the course of the investigation, the Department reviewed documentation including, but not limited to, Medication Administration Record (MAR) for (3) residents for Dec 2020 and/or Jan 2021, photos (2) submitted to the Department on 1/6/2021, staffing schedule for January 2021, Night Activity Reports, and other documentation. The Department interviewed the Administrator, (7) staff, (7) 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:
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: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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: 02/10/2022
NARRATIVE
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Complaint alleges that medications meant for residents are left out on tables, with glasses of water, and are not being given to the residents.

The Department was provided with a photograph in January 2021 of what appears to be a small table or nightstand next to a resident’s bed with (2) Styrofoam cups and (6) disposable paper medication cups, containing (1) to (3) pills each. The photo also shows a pair of reading glasses next to one of the Styrofoam cups. Information obtained during the investigation revealed that the photo was taken from resident R1 room on/around January 2021. During an interview with resident R1 on 10/21/2021 in R1’s room, LPA Calzada observed an identical looking box, to that of the one in the photograph provided, with a purple side facing R1’s front door, and a black top, to be next to the air/heater unit and bed. Additionally, the top of the box observed in R1’s room had a piece of clear packing tape down the middle as well as a slightly tattered top corner, as shown in the photograph.

R1, who does not have a diagnosis of Dementia, indicated that he has had the box in his room for about (3) years and "uses it as a piece of furniture". R1 indicated that he keeps one or two Styrofoam cups of water, usually, on the box, as he uses as a table. R1 was shown the photo and asked if he has ever observed medication cups to be in his room, as shown in the photo. R1 stated that he has never seen his medications look like the medications in the photo, and that he always takes his medications when they are administered to him. R1 stated in a follow up interview on 11/10/2021, “I have never refused and if I would, I would tell the Med-Tech".
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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: 02/10/2022
NARRATIVE
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Interviews with (2) med-techs confirmed that the round, brown tablet pictured in the medication cups in the photo is the medication, Senna; however, neither staff was able to identify the round, white pill, also pictured. Review of R1’s Medication Administration Record (MAR) for December 2020 and January 2021 showed that R1 was scheduled to take (2) Senna 8.6 mg tablets and (1) Zetia 10 mg tablet, which can be either round or oblong, for bedtime medications. The MAR documentation reviewed for multiple months, including for December 2020 and January 2021, showed that neither medication was refused at any time by R1.

R1 was asked if facility staff stay and watch him take his medications when they are administered, and R1 stated “"sometimes they watch and sometimes they just give it and go". A housekeeper stated in an interview that she has never seen medications left out as shown in the photograph and medications are consistently locked in the medication room.

The Department finds that the box and medications in the photo provided match the box observed in R1’s room and the medications prescribed to R1; however, based on insufficient information provided as to a day/time the photo was taken, R1’s statements and MAR documentation reviewed, it cannot be established by a preponderance level of evidence that the medications shown in the photo were left out unsecured.

Complaint alleges that certain residents are not being "lifted" or woken up so that they can be fed breakfast, and they are not always getting their meals. There were no specific resident names provided with the complaint.

One caregiver stated that “there are a few residents that need help and the kitchen will get trays to those residents.” Residents interviewed, in May 2021, indicated that they are now going to the dining room for meals.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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: 02/10/2022
NARRATIVE
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Administrator stated by email on 10/20/2021, “yes, there were a few residents who were on hospice from January until around spring whom we fed while in bed and sat up to eat meals. We would get them out of bed earlier on when they were strong enough to do so. However, once their conditions progressed, we used their remotes to lift them to a sitting position in bed and fed them their meals and beverages. Because they were hospice and had fewer less appetites, we would only feed them as much as they desired to eat. “

Based on information obtained, the Department finds the allegation 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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8