342700186-9-28-2023-59-AS-LMUZ-CWGRZN-20231010132812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 09/28/2023
Date Signed: 09/28/2023 04:35:37 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
09/05/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230905164434

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:	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lacy Berry		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff dispensed the wrong medication to a resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analaysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced to continue the investigation for the complaint the Departmenet received on 9/5/2023. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit.

During the course of this investigation, the Department conducted interviews, file reviews and a medication audit of R1.

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: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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-20230905164434

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: 09/28/2023

NARRATIVE

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Allegation: Staff dispensed the wrong medication to a resident while in care.

Based on LPAs' medication audit conducted on 09/28/2023, the audit included comparing R1's Medication Administration Record (MAR) with R1's medications, medication start dates and physician’s orders. During LPAs' medication count, (1) staff med tech was present at all times.

Based on the medication audit conducted, file review of R1's MAR revealed on September 4th and September 5th, PM med tech did not sign that medications were administered to residents in care. LPAs conducted a medication count with S1 of R1's Glipizide. LPAs observed R1's physician order for Glipizide is to take two tablets by mouth two times a day 30 minutes before meals. LPAs observed bottle start date to be 8/31. During medication count, LPAs and S1 observed the Glipizide bottle of 120 tablets to have 11 tablets remaining, which means 109 tablets has been dispensed. Based on the signatures and/or initials on the R1's August 2023 and September 2023, total medication signed off totaled to 108 tablets, two tablets on AM shift of August 31, 2023 and 106 tablets month of September 2023. LPAs and S1 observed one tablet to be missing from R1's medication bottle and not accounted for.

Based on the allegation, staff dispensed the wrong medication to a resident while in care, 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, copy of report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230905164434

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: 09/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 09/29/2023 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:	1 2 3 4 5 6 7	An office meeting will be held to discuss this matter. LPA will reach out to Administrator and Licensee representatives to schedule a meeting.
	8 9 10 11 12 13 14	Based on observation of medication audit, Licensee comply to the section cited above as LPAs observed R1's medication to have one tablet missing from the original bottle which was also not signed off on the MAR, which poses an immediate 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: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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