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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 10/19/2022
Date Signed: 11/17/2022 01:53:15 PM


Document Has Been Signed on 11/17/2022 01:53 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/17/2022 09:11 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

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**This report was amended on 11/17/22 only to obtain a signature from the facility on the 9099/9099C pages as it was inadvertently not obtained when the report was delivered on 10/19/22. There are no other changes.**

Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to continue a complaint investigation. LPA met with Lacy Berry, Administrator and explained the purpose of the visit. LPA later met with Veronica Sison, Resident Care Coordinator. Prior to initiating the complaint visit, LPA completed required COVID-19 protocols, and wore the following Personal Protective Equipment (PPE): surgical mask. Additionally, LPA was screened by facility staff upon entering the facility.

While at the facility, interviewing several residents, LPA observed the following deficiencies:

At approximately 10:00 am, at the start of interviewing resident (R1), LPA observed R1 to have poured cough syrup on her breakfast tray. R1 stated the medication was delivered to her for her to take, before she eats breakfast, due to stomach issues. LPA notified a Med-Tech (S1) that staff must watch residents take their medication as part of administering it. LPA observed R1 to take the cough syrup in the presence of S1. Additionally, LPA observed nasal spray to be sitting on R1's night stand, unsecured.

At approximately 11:00 am, LPA observed resident (R2) to be sitting near the door to her room that was partially opened, while opening a small bottle of medication and pouring 2-3 tablets in her hand. LPA knocked on the door to request to interview resident. LPA observed resident put the tablets back in the bottle and place the bottle in the storage area of her walker next to her.

At approximately 1:00 pm, LPA observed resident (R3) to be sitting in her room with the door open and to have a bottle of Glucose tablets (50) in her room on a table. R4 immediately took the bottle and placed it in a drawer on the other side of her room. LPA spoke to Administrator about it who confirmed the RCC removed the bottle from R3's room around 4:15 pm today.

cont on 809C(1)...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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: 10/19/2022
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809C(1)..At approximately 1:30 pm, LPA observed resident's (R4)'s room open and R4 to be sitting in his room, using oxygen. LPA observed multiple tanks in his room. R4 told LPA he uses an inhaler in the morning and another one in the evening and showed LPA he had both inhalers stored in an unlocked drawer. LPA observed a small bottle of Ibuprofen to also be in the drawer with the inhalers. LPA discussed the situation with Administrator who requested RCC remove the Ibuprofen immediately. R4 stated to LPA until recently he kept both inhalers on the top of his dresser and was asked by a NOC staff to put them in the drawer. Administrator provided a copy of a physician's order stating R4 is authorized to keep Tiotropium-Olodaterol (Stiolto Respimat) 2.5-2.5 mcg/actuation Inhl Mist in his room and agreed to arrange for him to get a lock box for R4 to keep the inhalers in.

At approximately 3:40 pm, LPA and Administrator discussed medication with resident (R5) in his room and asked if he was storing any in his room LPA and Administrator observed R5 open a top drawer of his dresser and pick up a medication cup containing (5) tablets, (4) white tablets and (1) red tablet. Administrator immediately requested R5 give her the medication and explained that it has to be secured with all of the other medications.


Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 809D page.

Exit interview. Copy of appeal rights provided.


SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2022 05:48 PM - It Cannot Be Edited

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: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/21/2022
Section Cited

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:

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Administrator agreed to ensure resident (R4) gets a locked box so he can secure the inhalers. Administrator and RCC also spoke to the family members of R2 and R4 advising that residents cannot return to the faciltiy with any medications at all.
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Based on observation, LPA observed multiple unlocked medications in residents' rooms on 10/19/22 from 10::00 am- 3:40 pm, which poses an immediate health and safety risk to residents in care. RCC or Administrator promptly removed the unlocked medications.
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Today, there was mandatory staff training, per the Stipulation, and the topic was Medication Management. Allen Flores Consulting Group to send a copy of the Power Point and attendees to CCLD by 10/21/22.

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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: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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