342700186-8-23-2023-25-AS-LMUZ-CV2U5D-20230825151632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 08/23/2023
Date Signed: 08/23/2023 11:28:15 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2022 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20221208121756

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: 61	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Lacy Berry		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not keep the facility clean and sanitary.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced to deliver complaint findings to a complaint the Department received on 12/08/2022. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit.

During the course of the investigation, the Department interviewed Administrator, Long Term Care Ombudsman (LTCO) Ronald Carrera, (2) residents (R1 and R2) and (2) family member of resident (R1). Additionally, the Department conducted extensive record reviews, including but not limited to, R1’s physician report for RCFE, R1’s Needs and Service Plan, R2’s physician report for RCFE, R2’s Needs and Service Plan, LTCO’s complaint report and Sacramento County Sheriff Department Report.

**Please continue on LIC 9099-C**

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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-20221208121756

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WALNUT HOUSE	FACILITY NUMBER: 342700186
	VISIT DATE: 08/23/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LIC 9099-C

The result of the investigation is as follow:

Allegation: Resident engaged in sexual interactions with another resident in care.

Based on interview conducted with Administrator revealed R1 and R2 are just friends who often go on walks and read books together. Administrator denied seeing R1 and R2 being inappropriate and/or knowing if R1 and R2 go to each other’s room. Based on interview with R1 revealed R1 was unable to remember the name of the current President of the United States and the current year. R1 stated R2 is a friend. Interview with R1 revealed R1 is unable to remember if R1 and R2’s “physical relationship” was a dream or real but confirmed R1 and R2 consented. Based on interview conducted with R2 revealed R2 was unable to state R2’s age, address, and/or the current President of the United States. R2 stated it “rings a bell” when asked if R1 and R2 are friends. Based on interviews conducted with R1’s family members revealed R1 may be delusional as a result of R1’s urinary tract infection and dementia. Interview further revealed R1 and R2’s relationship was a “platonic relationship” as R2 is R1’s “buddy”.

Based on records review, it revealed that R1 was not having consensual and non-consensual sex with anyone. R1 indicated R1 does not have any issues with R2.

Based on information obtained through interviews and records reviewed, the Department finds the allegation to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of the report and appeal rights was left with Administrator.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2