342700186-8-23-2023-25-AS-LMUZ-CVEUWM-20230906155659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 08/23/2023
Date Signed: 08/23/2023 11:38:20 AM

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
01/23/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20230123151735

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:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:			TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff are restricting resident's personal activities.

INVESTIGATION FINDINGS:

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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 01/23/2023. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit.

During this investigation, the Department conducted interviews and file review.

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: 08/23/2023

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)

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Control Number 25-AS-20230123151735

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

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LIC 9099-C

Allegation: Facility staff are restricting resident's personal activities.

The Department has conducted interviews and record review for the allegation cited above. Based on the interview with Administrator on 1/26/2023, it revealed there was conflict regarding residents exiting the dining room sliding door to go outside to smoke. Interview with Administrator revealed Long Term Care Ombudsman was involved and advised the facility to implement a smoking schedule of 10 minutes after each meal to create fairness to all residents in care. Based on interview conducted with R1 revealed it was not true that staff are restricting residents to one cigarette per hour, but facility is enforcing a smoke schedule for after meals.

Based on file review conducted, LPA reviewed the House Rule in the Admission Agreement. File review revealed under section “Smoking” to only state “There is no smoking within the facility. There are designated smoking areas that both residents and staff shall use.” The file review does not reveal a rule on smoking during mealtime.

Based on information obtained through Facility Administrator, R1 and file reviewed, the Department finds the allegation to be 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: 08/23/2023

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)

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Control Number 25-AS-20230123151735

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: 08/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/30/2023 Section Cited CCR 87468.2(a)(6)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee is to submit an addendum to House Rules implementing the 10 minutes after mealtime smoking rule to CCLD by 8/30/2023. Licensee is to provide all residents in care the copy of the House Rule addendum immediately.
	8 9 10 11 12 13 14	Based on interviews and file review, Licensee did not ensure that residents have the rights to make choices concerning their daily lives in the facility as smoking residents are to wait 10 minutes after mealtime in able to go outside to smoke, which poses a potential health safety and personal rights risk to residents in care as it is not listed in the House Rules.	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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

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