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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700186
Report Date: 07/01/2021
Date Signed: 07/01/2021 07:04:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 57DATE:
07/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Lacy Berry, Administrator TIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings and issue a citation for a deficiency found during the course of the complaint investigation.

LPA met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, confirmed with the facility there are currently no positive Covid-19 diagnoses and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask.

Resident representative stated he was not notified by the facility when resident fell and was sent out to the Emergency Room on 2/7/2021, but he was informed by the hospital. LPA reviewed LIC624 for incident occurring on 2/7/2021. and it notes that resident was sent out around 4:50 pm and that resident's representative had been notified at the contact number on file for resident's representative. . Phone records provided by resident's representative for the month of February 2021, do not show that an incoming call was made by the facility and received by resident's representative on 2/7/2021 following resident's fall. Phone records provided match the contact information on file for resident's representative.

Based on information obtained, the following (1) deficiency was found and a citation is being issued on LIC809D.

Exit interview. Copy of report and appeal rights printed and provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
This requirement is not met as evidenced by:
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Based on interview and record review, the Licensee did not ensure that resident's representative was contacted on 2/7/2021 following resident's (R1) fall and being sent out for further medical evaluation around 4;50 pm, which posed a potential personal rights violation 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) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021
LIC809 (FAS) - (06/04)
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