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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 12/30/2020
Date Signed: 12/30/2020 01:52:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 56DATE:
12/30/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lacy Berry, Administrator TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada conducted a tele-visit due to current Covid-19 precautionary measures in place. LPA met with Lacy Berry, Administrator, and explained that the purpose of today's tele-visit is to cite additional deficiencies based on information revealed during complaint investigation, 27-AS-20200515160116, as follows:

On 5/10/20, the facility contacted an alternative emergency ambulance medical services provider rather than 911 for resident (R1). Documentation reviewed and interviews conducted confirmed that emergency ambulance medical services were contacted due to resident (R1) having an altered level of consciousness, slurred speech and being unresponsive to basic commands.

The investigation revealed an insufficient staffing ratio of 2-3 caregivers for 58-65 residents, resulting in an overdose of Tylenol medication for resident (R1).

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) deficiencies were found and citations are issued. Failure to correct the deficiency by the noted due date may result in a penalty(ies) being assessed.

Exit interview. Copy of report and appeal rights provided.




SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/08/2021
Section Cited

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87465 Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by:
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Based on interviews conducted and documentation reviewed, the Licensee did not contact 911 on 5/10/2020 for resident (R1), who was described as unresponsive, which posed an immediate health and safety risk to resident in care.
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Request Denied
Type A
01/15/2021
Section Cited

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87411(a) Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Based on interviews conducted and documentation reviewed, a staffing ratio of 2-3 caregivers for 58-65 residents was revealed, and the Licensee did not ensure there were sufficient staff to meet residents' needs, which resulted in resident, R1, overdosing on Tylenol medication, which posed an immediate health and safety risk to resident in care.
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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) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2