342700186-1-25-2024-59-AS-KHOS-CZZMDJ-20240131083112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:54:07 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
01/25/2024 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20240125123831

FACILITY NAME:	WALNUT HOUSE		FACILITY NUMBER:	342700186
ADMINISTRATOR:	VICKY CROSS		FACILITY TYPE:	740
ADDRESS:	3401 WALNUT AVE		TELEPHONE:	(916) 483-6612
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	110	CENSUS: 67	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Vicky Cross, Lacy Berry, Allision Lopez, Veronica Sison		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff mishandled resident's medication.

INVESTIGATION FINDINGS:

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On 1/25/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open and deliver the findings of the allegation cited above. LPA met with Administrator, Vicky Cross, and explained the purpose of the visit.

Today's investigation, LPA obtained a copy of R1, R2, R3, R4, and R5's January 2024 medication administration records (MARs). LPA conducted a medication count for R1 and R2. Additionally, LPA took photos of R1's medication packets for reference.

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: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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 4

Control Number 59-AS-20240125123831

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: 01/25/2024

NARRATIVE

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LIC 9099-C...

Allegation: Staff mishandled resident's medication.
Based on the file review of R1's January 2024 MAR, it revealed R1 is to take Eliquis 5mg tablet, twice a day. January 2024 MAR revealed the prescribed medication was signed for on January 20: AM and PM, January 21: AM and PM, January 22: AM and PM, January 23: AM and PM, January 24: AM and PM and January 25: AM. R1's MAR revealed Eliquis was given six (6) times during AM shift, starting January 20. R1's MAR revealed Eliquis was given five (5) times during PM shift, starting January 20.

Based on LPA and Regional Nurse medication audit, it revealed R1's AM Eliquis 5mg packet's start date was labeled as January 20, 2024. Based on the medication count, LPA and Regional Nurse observed four (4) tablets to be missing from the AM packet, instead of 6 as documented on R1's MAR. Based on LPA and Regional Nurse medication audit, it revealed R1's PM Eliquis 5mg packet's start date was labeled as January 20, 2024. Based on the medication count, LPA and Regional Nurse observed three (3) tablets to be missing from the PM packet, instead of 5 as documented on R1's MAR.

Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Magox 400mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Magox was given 5 times, starting January 21.

Based on LPA and Regional Nurse medication audit, it revealed R2's Magox 400 mg medication bottle's start date was labeled as January 21, 2024. Based on the medication count, LPA and Regional Nurse counted 96 pills present in the bottle out of 100 tablets, meaning 4 tablets to be missing, instead of 5 as documented on R2's MAR.

Please continue the report on LIC 9099-C2...

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20240125123831

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: 01/25/2024

NARRATIVE

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LIC 9099-C2...

Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Januvia 25mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Januvia was given 5 times, starting January 21.
Based on LPA and Regional Nurse medication audit, it revealed R2's Januvia 25mg medication bottle's start date was labeled as January 21, 2024. Based on the medication count, LPA and Regional Nurse counted 26 pills present in the bottle out of 30 tablets, meaning 4 tablets to be missing, instead of 5 as documented on R2's MAR.

Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Plavix (Clopidogrel) 75mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 12, January 13, January 14, January 15, January 16, January 17, January 18, January 19, January 20, January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Plavix (Clopidogrel) was given 14 times, starting January 12.

Based on LPA and Regional Nurse medication audit, it revealed R2's Plavix (Clopidogrel) 75mg medication bottle's start date was labeled as January 12, 2024. Based on the medication count, LPA counted 91 pills whereas Regional Nurse counted 90 pills present in the bottle out of 100 tablets, meaning approximately 10 or 11 tablets to be missing, instead of 14 as documented on R2's MAR. When asked if recount is needed, Regional Nurse stated "90, 91 is close, but there is supposed to be 86 (tablets) in here".

Based on the allegation, staff mishandled resident's 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 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: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20240125123831

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: 01/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/26/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	This matter will be discussed during noncompliance conference on 1/31/2024. Deficiency will be cleared afterwards.
	8 9 10 11 12 13 14	Based on file review of R1 and R2's medication administration records and medication audit, licensee did not comply with the section cited above as LPA and Regional Nurse observed four different medication counts to be inconsistent with MAR, which poses an immediately risk to residents in care.	8 9 10 11 12 13 14
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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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

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