342700186-1-11-2024-59-AS-KHOS-CZRSXN-20240123131614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:33:56 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
08/29/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230829093013

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: 67	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Lacy Berry		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not following residents care plans.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/11/2023, Licensing Program Analyst (LPA) Cassie Yang 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, LPA conducted file reviews and interviews.

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: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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 3

Control Number 59-AS-20230829093013

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: 01/11/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LIC 9099-C...

Allegation: Staff are not following residents care plans.
Based on file review of R1's care plan, it revealed R1's medication management states "Needs/Details Central storage and set up of medications Assistance with 10+ centrally stored medications" Based on LPA's inspection conducted on 10/11/2023, it revealed medications were found in R1's bedroom when it should be centrally stored responsibility of a med tech as stated in R1's care plans. LPA observed the medication found to be Ondansetron 4mg which is often used to nausea and vomiting. Interview revealed R1 wished to keep Ondansetron in the room as it is hard to get assistance for medication in a timely manner. It further revealed when call lights are pressed, R1 is unable to get assistance until an extensive period of time. Interview with R1 further revealed that R1 needs assistance with showering and incontinence care but often staff are unavailable to change diaper in a timely manner. Based on LPA's observation on 10/11/2023, it revealed LPA observed R1 pressing call light for assistance. At approximately 15 minutes afterwards, LPA checked on R1 which revealed no caregiver has entered the room for assistance yet.

Interview with R2 revealed R2 needs assistance with medication as medications are centrally stored. R2 stated med techs are often late for medication administration as facility is often employed with one med tech per shift only.

Interview conducted with R3 revealed R3 has occasional issues with call lights at the facility, as staff do not respond until over "10-15 minutes". Interview with R3 revealed R3 is not concern if call is not responded if it is regarding needing clean up assistance. R3 stated R3's concern is if the call light is in regards to an emergency, R3 is unsure other residents can wait that long for help.

Based on the allegation, staff are not following residents care plans, 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.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20230829093013

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: 01/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/26/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staffing concerns will be discussed with Licensee during in-person noncompliance conference.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above as R1 and R2 both stated there is staff shortage at the facility resulting to delays on level of care, which poses a potential health and safety risk for 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: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3