342700186-4-24-2024-59-AS-APEZ-D4PLWX-20240426090750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 04/24/2024
Date Signed: 04/24/2024 12:25:13 PM

Unsubstantiated

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
05/05/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230505093715

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: 68	DATE:	04/24/2024
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Vicky Cross		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

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Staff does not respond to call in a timely manner.
Staff are not meeting resident's showering needs.
Staff did not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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On 4/24/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver findings of the allegations cited above. LPA and LPM met with Administrator, Vicky Cross, and explained the purpose of the visit.

During the course of this investigation, the Department conducted extensive interviews and file reviews.

The results of the investigation is as follow.

Please continue on LIC 9099-C**

Unsubstantiated

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: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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-20230505093715

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: 04/24/2024

NARRATIVE

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***LIC 9099-(C)(1)***
Allegation: Staff does not respond to call in a timely manner.

The Department conducted interviews regarding the allegation cited above. Interview conducted with R1 revealed the facility does not respond to call lights in a timely manner when R1 needs assistance with rotating and/or transferring. Interview conducted with R2 revealed R2 utilizes the call light for assistance with taking the trash out. R2 revealed R2 does not mind if staff takes longer to respond as it is not an emergency. Interview conducted with R3 revealed the PM shift did not assist to call lights in a timely manner. Interview further revealed R3 usually waits approximately 20 to 30 minutes when utilizing call light.

File review conducted for R1 revealed the longest response time for a call was to be 75 minutes. Interview conducted with R1 revealed R1 does not recall what assistance was needed at that time. R1 stated no fall and/or serious injury occurred during the time period of the call logs. File review conducted for R4 revealed the longest response time for a call was to be 98 minutes. Interview was unable to be conducted with R4 as R4 declined to speak to LPA. Although file review revealed there was long call response, California Code of Regulation, Title 22, does not specify a time frame of when facility is to assist to a non-emergency call. Additionally based on interview with Regional Director, it revealed that facility staff has the tendency to "forget to reset the system at the conclusion of the service they are doing". Therefore the allegation cited above is unsubstantiated.

Allegation: Staff are not meeting resident's showering needs.

The Department conducted interviews and file review regarding the allegation cited above. Interview conducted with R1 revealed R1 does not like certain caregivers to shower R1 as R1 feels unsafe that certain caregivers are untrained to utilize the shower transferring machine. Interview further revealed R1 will refuse showers and ask for a new caregiver. Interview conducted with R4 revealed that R4 does not like "rude" caregiver to shower R4 and would ask for a new caregiver to provide showering. Interview conducted with S1 revealed S1 has received complaints regarding R4 yelling at caregiver to "get the hell out". Interview further revealed that caregivers are to complete refusal forms for residents in care when showers are declined. Based on file review, LPA observed shower refusal forms to be completed for residents in care. File review revealed shower skin inspections for R4 which are documented when showering are completed. The allegation cited above is found to be unsubstantiated.

Please continue on LIC 9099-C (2)

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230505093715

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: 04/24/2024

NARRATIVE

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***LIC 9099-C (2)***
Allegation: Staff did not safeguard resident's personal belongings.

The Department conducted observation and interviews regarding the allegation cited above. Based on LPA's observation, it revealed each resident room at the facility has a door lock to ensure personal safeguarding. Interview conducted with R1 revealed R1 has lost "a couple of shirts" but is unsure if it is in the closet or not. The Department conducted an interview with R2 which revealed R2 has noticed a pair of pants to be missing. Interview conducted further reviewed R2 cannot confirm if it was do to laundry error or not. Interview conducted with R3 revealed R3 does not have an issue regarding missing personal belongings. Therefore, the allegation cited above is unsubstantiated.

A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted. A copy of this report was been provided. Signature on form acknowledges receipt of these forms.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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