342700186-8-24-2023-25-AS-LMUZ-CVEUV6-20230906155437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 08/23/2023
Date Signed: 08/24/2023 05:30:40 PM

Unfounded

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
01/18/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20230118170306

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: 61	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Lacy Berry		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility did not issue a refund.
Facility did not notify responsible party that resident relocated to another facility.

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 01/18/2023. LPA and LPM met with Administrator, Lacy Berry, and explained the purpose of the visit.

Please note, this report is amended to reflect current allegations.

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

The result of the investigation is as follow.

**Please continue on LIC 9099-C**

Unfounded

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)

Page: 1 of 3

Control Number 25-AS-20230118170306

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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Allegation: Facility did not issue a refund.

The Department has conducted interviews and file review for the allegation cited above. Based on the interview with Administrator revealed resident (R1) was was sent out to the hospital for stroke-like symptoms end of June 2022. Administrator stated R1 was discharged to a skilled nursing facility while R1's personal belongings remained in her room at the facility. Interview with Administrator revealed R1's personal belongings were not removed from the facility until August 2022.

Based on file review conducted revealed the Admission Agreement page 15, section Refund, states "Within twenty-one (21) business days after you vacate and remove all of your property from your Room, we shall refund to you or your estate any amounts we owe to you, minus (i) any Monthly Fees, fees for additional items and services, or other charges you owe to us..."

The Department found the allegation to be unfounded.

Allegation: Facility did not notify responsible party that resident relocated to another facility.

The Department has conducted interviews and file review for the allegation cited above. Based on the interview with Administrator revealed resident (R1) does not have any responsible party listed in R1's file.

Based on file review conducted, document revealed in R1's LIC 601 Identification and Emergency Information, signed and dated on 8/8/19, LPA observed "Self" listed in the "Responsible Person or Placement Agency".

Based on information obtained through interviews and records reviewed, the Department finds the allegation to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of the report and appeal rights was left with 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-20230118170306

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 CCR	1 2 3 4 5 6 7	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	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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