342700186-5-4-2023-25-AS-KHOS-CRLVW6-20230507164724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:06:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20221201083301

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: 62	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Lacy Berry, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Resident was hit by another resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Lacy Berry, to deliver findings into the complaint allegation listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Resident was hit by another resident in care

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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-20221201083301

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: WALNUT HOUSE	FACILITY NUMBER: 342700186
	VISIT DATE: 05/04/2023

NARRATIVE

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Relevant party reported that resident (R1) had indicated that an individual at the facility hit them. A description of the suspect was provided to the Department.

Interviews with staff members S1, S2, S3, S4, and S5, residents R2 and R3, and Administrator stated that they had not witnessed any incidents of a resident being hit at the facility. Interviews with the above individuals indicated that no one (resident nor staff) matching the description of the suspect provided to the Department has been at the facility.

Interviews with relevant parties indicated that R1 was exhibiting behaviors of confusion around the time that incident was reported.

LPA reviewed Home Health Care Notes and Special Incident Reports (SIRs) for R1. No documentation reviewed indicated any complaints about physical abuse. R1's Physician's Report for RCFE (LIC 602A) signed 9/23/2021 indicated R1 as having a primary diagnosis of Alzheimer's Disease unspecified. R1's LIC 602A dated 10/20/2022 indicated R1's primary diagnosis as an unstable burst fracture of first lumbar vertebra.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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