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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 07/01/2021
Date Signed: 07/01/2021 06:59:51 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2021 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210416095424
FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:LACY BERRYFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 57DATE:
07/01/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lacy Berry, Administrator TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff failed to safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver investigation findings to a complaint received by the department on 4/16/2021. LPA met with Lacy Berry, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, confirmed with the facility there are currently no positive Covid-19 diagnoses and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical Mask.

During the course of the investigation, LPA interviewed Administrator, Ombudsman, (1) caregiver, (1) med-tech, (1) housekeeper, (4) residents and resident's representative. LPA reviewed documentation including, but not limited to, charting notes regarding discussions of missing items, Resident Personal Property and Valuables (LIC621), receipts of clothing and other items purchased by facility and resident representative, Medication Administration Record (MAR), Unusual Incident/Injury Report (LIC624), and photographs provided by resident representative of empty closet and drawers.
cont on 9099C..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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 5
Control Number 25-AS-20210416095424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
VISIT DATE: 07/01/2021
NARRATIVE
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Resident (R1) who is the subject of the complaint moved to the facility on/around December 2018 and moved from the facility on/around April 2021. Resident was not available for an interview. Complaint alleged that much of resident's clothing, and her comforter, had gone missing from the time she moved to the facility, as well as resident's expensive shoes, glasses and partial tooth plate. Complaint alleged that resident was wearing other residents' clothing since hers had gone missing.
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Interviews with (4) residents revealed the following: one resident stated she has lost a lot of her clothes, especially socks, even though her socks were marked with her initials; another resident indicated she has never lost any clothing, and she marks all of her clothes; a third resident stated she is not sure if any of her clothes or laundry have disappeared and a fourth resident stated none of his clothing or laundry has ever disappeared.

LPA interviewed one staff who stated she is not aware that resident (R1) has lost any clothing or bedding items, but it's possible something could be misplaced if the staff returning the clean laundry to her room didn't pay enough attention. Two staff interviewed indicated that resident had a roommate prior to moving out and it's very possible that the resident's roommate's family may have inadvertently taken resident's (R1) belongings with them when they moved their family member out.

Another staff confirmed that caregivers do the laundry and "we have a system- we put a whiteboard on the washer and dryer" showing who the clothing belongs to so it can be returned to the correct resident. Administrator stated in June 2021 that she purchased a "magnetic board" 4 months ago to write the resident's name on which sticks to the washer and dryer to identify who the clothing belongs to and confirmed that there have not been any clothes that have disappeared since the system was implemented. Administrator added "things do disappear in Assisted Living but we always stress finishing the laundry- whoever starts the load finishes it and to also communicate during changeover". Staff also will search for any missing items once reported.

Resident's representative stated to LPA that he listed "clothes" on the LIC624 when resident moved to the facility but did not list each clothing item individually. Charting notes dated 4/7/2021 indicate that resident's representative stated he had not listed resident's clothing on the LIC621 when asked by the Administrator during a meeting with the Ombudsman present. LPA reviewed initial LIC621 provided by Administrator which shows that the only items as of 12/21/18 were a dresser and picture. On 1/5/2019 a toilet seat was added to the LIC621, and sheets .a bed spread were added on 10/15/2019. Administrator stated "we always do an inventory form- we ask the POA's to return it but some don't" and Administrator will complete the LIC621 if POA doesn't return it.

cont on 9099C(2)...

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20210416095424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
VISIT DATE: 07/01/2021
NARRATIVE
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9099(C)(2) Charting notes dated 4/7/2021 state that resident representative came to pick up resident for an appointment and contacted Administrator later in the day to report that some of resident's clothing and comforter were missing and the toilet seat riser in her bathroom did not belong to her. Notes state that Administrator confirmed with resident's caregiver that it was resident's laundry day and her clothes were in the washer. Additionally, the notes document that resident's comforter had been recently replaced when it was reported as missing, even though it was not listed on the LIC621. Notes further state that Administrator indicated that she would purchase some new clothing and replace the toilet seat riser, even though there was already one in resident's bathroom. Notes document that resident's representative stated he did not want Administrator to purchase resident any clothing, and he would be calling the Ombudsman. Receipts provided by the Administrator show that multiple clothing items and a comforter were purchased on 4/7/2021 (20:39 hours). Resident's representative provided (2) receipts showing clothing he had purchased on 4/14/2021 and on 4/24/2021, for resident. LPA reviewed a subsequent LIC621 completed on 4/7/2021 by the Administrator following the purchase of the items. Administrator stated that resident was familiar with her clothes and would wear her clothes only, and she would only hang up the clothes that belonged to resident.

Charting notes dated 4/9/2021 note that Administrator received a call from a staff member stating that resident's representative was at the facility on the evening of 4/8/2021 to drop off "2 new shirts, 2 pairs of pants and a sweater for his mother" and he instructed staff to remove all of the items that had been purchased on 4/7/2021 from resident's room. Final meeting notes dated 4/15/2021 document a meeting held between the Administrator, resident's representative and the Ombudsman. It was discussed that new sneakers just purchased by resident's representative for resident needed to be added to the LIC621, and it was agreed that resident's representative would do resident's laundry himself and not bring any expensive items to the facility. It was agreed that a new toilet seat riser would be purchased by facility maintenance today as well. Receipt provided by the Administrator shows that a toilet seat riser was purchased on 4/15/2021 (10:12 am).

Interview with resident's representative indicated that the first item to disappear was resident's expensive pair of shoes, on/around 2019, which were returned to resident's room, under her bed, 4 weeks later. Resident's representative stated that resident's clothing and the comforter were the next items to disappear, along with resident's prescription glasses and dentures. Administrator was not aware that resident's glasses or dentures had gone missing as they were not reported as missing and resident was always observed to be wearing both.

cont on 9099C(3)..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20210416095424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
VISIT DATE: 07/01/2021
NARRATIVE
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9099C(3)... LPA and Administrator discussed Regulation 87218 and Health and Safety Code 1569.153. LPA confirmed that facility theft and loss policy is posted. Administrator stated that staff receives training during orientation of facility theft and loss policy. Administrator confirmed that the facility has not maintained a documented theft and loss record to document missing items, with a value of $25 or greater, and within 72 hours of being reported as missing. Licensee/Administrator did replace/attempt to replace resident's missing property, even though it was not documented on the LIC621; however, there was no theft and loss record maintained for LPA to review.

The following additional concerns were brought to LPA's attention and investigated during the course of this investigation:

1) Facility was not giving resident regular showers- Interviews confirmed that resident was scheduled to receive two showers per week and resident would sometimes refuse a shower or didn't want to wash her hair, stating "she didn't feel good" . Another staff interview revealed resident may have refused a shower when it was changed to the "pm" shift, temporarily. Administrator stated that resident never refused showers and always allowed staff to wash her hair.

2) Facility was not washing resident's hair- Staff stated that sometimes resident didn't want her hair washed and resident liked to brush her own hair and staff would help her pin it up in a bun.

3) Facility did not stop Elliquis medication before resident went to her dental appointment. Resident representative and facility were unable to produce a physician's order that the medication should be stopped prior to a dental appointment. Ombudsman explained this to resident's representative also during the meeting held on 4/15/2021.

LPA was not able to substantiate the (3) additional allegations.

Based on information obtained, LPA finds the allegation: Staff failed to safeguard resident's personal belongings to be substantiated- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview. Copy of report and appeal rights printed and provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20210416095424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WALNUT HOUSE
FACILITY NUMBER: 342700186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited
CCR
87218(a)(2)(A)
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87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153.
(A) A civil penalty shall be levied if the licensee or facility staff have not implemented the theft and loss program, or if the licensee has not shown clear and convincing evidence of its efforts to meet all of the requirements set forth in Section 1569.153. This requirement is not met as evidenced by:
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LIcensee/Administrator agree to review Regulatilon 87218 in an In-Service training and documentation and follow up needed on any reported lost items.

Documentation to be faxed to the department by 7/16/2021.
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Based on record review and interviews conducted, the Licensee did not ensure that reasonable efforts were made to ensure that each requirement in
Section 1569.153, specifically, that a theft and loss record for the last 12 months was made available for review, was met, in order to safeguard resident's property, which posed a potential personal rights violation to residents in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5