342700186-10-11-2023-59-AS-KHOS-CZRSXQ-20240123131615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 10/11/2023
Date Signed: 10/11/2023 06:41:02 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
08/29/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230829093013

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: 55	DATE:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Lacy Berry		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not ensure that medications are inaccessible to residents in care.

INVESTIGATION FINDINGS:

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On 10/11/2023, Licensing Program Analyst (LPA) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to open the complaint the Department received regarding the allegation cited above. LPAs met with Administrator, Lacy Berry, and explained the purpose of the visit.

During the investigation, LPAs conducted an inspection of R1's room and conducted file review of R1's records. 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: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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-20230829093013

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: 10/11/2023

NARRATIVE

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Allegation: Staff did not ensure that medications are inaccessible to residents in care.
The Department conducted interviews regarding the allegation. Interview conducted with Administrator revealed medications are centrally stored. Based on LPAs' observation conducted on 10/11/2023, it revealed R1 has medication in her room. LPAs observed the medication was in a lockbox located in her bathroom. Interview conducted with R1 revealed R1 has frequent nausea and keeps the medication in her room because she is unable to get staff assistance in a timely manner. LPAs observed the medication found to be Ondansetron 4mg which is often used to nausea and vomiting.

Based on R1's most recent LIC 602 PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY on file, date of exam 06/22/2021, LPAs observed that R1 is unable to administer own prescription medications, R1 is unable to administer own PRN medications, and additionally, LPAs observed R1 is unable to store own medications.

Based on the allegation, staff did not ensure that medications are inaccessible to residents 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, and a copy of the report and appeal rights was provided via email as LPAs experienced technical difficulties.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230829093013

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: 10/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 10/12/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Medication is to be removed immediately and centrally stored. This matter will be discussed in office meeting with Licensees.
	8 9 10 11 12 13 14	Based on LPAs' observation and interview with R1, Licensee did not comply with the section above as LPA Yang and LPA Ratajczak observed R1 to have Ondansetron in her room, 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: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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