342700186-8-24-2023-59-AS-LMUZ-CV9PGL-20230901111827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 08/24/2023
Date Signed: 08/24/2023 05:51:50 PM

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
04/28/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230428133225

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:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lacy Berry		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility is not following resident care plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrievd unannounced at the facility to deliver findings of the allegations 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 and file review.

The result of the investigation is as follow.

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: 08/24/2023

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)

Page: 1 of 4

Control Number 59-AS-20230428133225

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: Facility is not following resident care plan.

The Department conducted a file review, it revealed R1 needed assistance with transfer based on needs and service plan from December 2022. The Department observed no notes and/or documentation regarding turning every two hours was observed in R1's care plan. Based on interviews conducted on 5/8/2023, facility staff stated there are no residents in care that required a two-hour turning.

Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint 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 report and appeal rights was provided.

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)

Page: 2 of 4

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
04/28/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230428133225

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:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lacy Berry		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility does not provide medication as prescribed.

INVESTIGATION FINDINGS:

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On 08/24/2023, Licensing Program Analyst (LPA) Cassie Yang and Licensing Program Manager (LPM) Laura Munoz arrievd unannounced at the facility to deliver findings of the allegations 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)

Page: 3 of 4

Control Number 59-AS-20230428133225

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: Facility does not provide medication as prescribed.

Based on LPA and LPM's medication audit conducted on 08/23/2023, 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.

The following allegations cited above are substantiated, but no deficiency will be as LPA substantiated the same allegation for complaint 25-AS-20220926150347 on 8/24/2023.

Exit interview conducted, 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)

Page: 4 of 4