342700186-8-24-2023-25-AS-LMUZ-CV7PBK-20230830111027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 08/24/2023
Date Signed: 08/24/2023 05:22:27 PM

Substantiated

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
09/26/2022 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20220926150347

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:	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lacy Berry		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff are mismanaging residents medication.

INVESTIGATION FINDINGS:

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On 08/24/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrived unannounced at the facility to deliver finding of the allegation cited above. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit.

During the course of this investigation, the Department conducted extensive interviews, file review, and conducted a medication audit.

The result of the investigation is as follow.

**Please continue on LIC 9099-C**

Substantiated

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: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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-20220926150347

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: 08/24/2023

NARRATIVE

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Allegation: Staff are mismanaging residents medication

On 08/23/2023, LPA and LPM conducted an audit of the medication room of the facility. The audit included comparing Medication Administration Records (MARs) with resident’s medications, medication start dates and physician’s orders. Additionally, LPM, with facility staff present, conducted a medication count of residents controlled medications.

Based on the medication audit conducted, MARs showed PM staff did not sign that medications were administered to residents in rooms #1-47. Days of missing signatures ranged from 3-6 days from the date of inspection.

A sample of resident’s medications were compared to the MAR signatures and the medication start dates. R1’s medications were reviewed and revealed that R1 had a medication ordered on 08/07/2023 which was to be given 3 times a day. Based on the medication count, facility staff failed to administer R1 16 doses of medication. R2’s medications were reviewed and revealed that R1 had a medication that started on 08/14/2023 which was to be given 2 times a day. Based on the medication count, facility staff failed to administer R2 9 doses of medication. LPM and LPA conducted the medication audit with the facility Administrator, Lacy Berry, and Regional Director, Robert Godfrey present.

Based on the allegation, staff are mismanaging residents medication, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency cited on LIC9099D.

Exit interview. Copy of report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220926150347

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/25/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical... provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee is to schedule a training for all Med Techs of how to complete the Medication Administration Record (MAR) correctly. Please notify LPA the date of training by Friday 8/25/2023. Licensee is to provide CCLD a copy of the training materials and list of attendees by Thursday 8/31/2023.
	8 9 10 11 12 13 14	Based on observation during medication audit, Licensee did not ensure medications were administered, as LPA and LPM observed MARs was not sign if medications were administered to residents, Rooms #1-47. Days of missing signatures ranged from 3-6 days from the date of inspection, which poses an immediate risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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