342700186-10-11-2023-59-AS-LMUZ-CWK2XM-20231012174718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 10/11/2023
Date Signed: 10/11/2023 06:38:35 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
10/10/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20231010142402

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: 55	DATE:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Lacy Berry		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility is in disrepair and unsanitary

INVESTIGATION FINDINGS:

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On 10/11/2023, Licensing Program Analyst (LPA) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to open the complaint the Department received regarding the allegation cited above. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit.

During the investigation, LPAs conducted an inspection of three bathrooms, interviewed two residents, and took 13 photos. 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: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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 59-AS-20231010142402

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: 10/11/2023

NARRATIVE

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Allegation: Facility is in disrepair and unsanitary.
On 10/11/2023, the Department conducted an inspection of R1's previous room and observed the bath tub faucet to be leaking while it was not in use. Interview conducted with R1 revealed that although R1 is not currently living in that room, the leaking has been ongoing prior to his temporary move to the room next door. R1 stated the reason why is was moved is not related to the leaking issue. Interview further revealed that R1 has informed Maintenance of this issue for months but it was never resolved. R1 stated the leak has caused molding in the tub when he used to reside in the room. Based on LPAs' observation, LPAs were able to see the leak has not been fixed and observed black and brown discoloration in the tub.

Based on LPAs observation of R1's current room, it revealed the bed frame to be in disrepair as the headboard was not correctly mounted to the wall, causing it to be slanted approximately eight inches away from the wall. Interview with R1 revealed it is a safety hazard as the headboard is not properly secured.

Additionally, based on observation of R1's current room, LPAs observed a strong odor of urine. Observation of R1's current bathroom revealed the bathroom floor to have multiple discoloration around the toilet. Interview with R1 revealed facility did not have housekeepers for months, so caregivers were in charge of the bathroom cleaning. Interview further revealed that the last housekeeping conducted, caregiver did not properly clean the bathroom floor.

Based on the allegation, facility is in disrepair and unsanitary, 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 allegation cited above is substantiated, please see LIC9099-D.

Exit interview conducted, and a copy of the report and appeal rights was provided via email as LPAs experienced technical difficulties.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20231010142402

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: 10/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 10/12/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Housekeeper was asked to clean R1's room and bathroom immediately. Licensee will notify LPA Yang when headboard and bathroom faucet is fixed. This matter will be discussed during office meeting with Licensees.
	8 9 10 11 12 13 14	Based on observation, Licensee did not comply with the regulation above as LPA Yang and LPA Ratajczak observed R1's room to have a strong odor of urine, unsecured headboard and multiple discoloration on bathroom floor, which poses an immediate health and safety 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: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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