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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 03/07/2024
Date Signed: 03/07/2024 04:28:48 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
02/26/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240226134705
FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:VICKY CROSSFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 71DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Vicky CrossTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not ensure resident's room is clean and sanitized.
INVESTIGATION FINDINGS:
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On 3/7/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an investigation regarding the allegation the department received. LPA met with Administrator, Vicky Cross, and explained the purpose of the visit.

During the investigation, LPA conducted an inspection of R1's bedroom. Addtionally, LPA conducted a file review of R1's care plan and LIC 602. LPA obtained two photo of R1's bedroom.

Result of the investigation is as follow.

Please continue on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 59-AS-20240226134705
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: 03/07/2024
NARRATIVE
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LIC 9099-C...

Allegation: Staff did not ensure resident's room is clean and sanitized.
The department conducted an inspection regarding the allegation cited above. Based on observation on 3/7/2024, it revealed R1's carpet by the bed was stained. The stain is observed to be a dark brown color and approximately two feet. Based on interview with R1, it revealed R1 had spilled a drink on the carpet. It further revealed that the stain has been there for the past "several weeks".

During LPA's observation, it revealed R1's bed linen and pillow case was stained with red streaks. Interview conducted revealed that the stains on the linen and pillow case has been present for "a couple of days".

Additionally, based on observation, it revealed that R1's urinal bottle was stored on top of the night stand with the presence of urine inside. Observation revealed that there was opened snacks on the night stand next to the urinal bottle. Interview conducted with R1 revealed that R1 does not get assistance from staff to help clean the urinal bottle.

Based on the allegation, staff did not ensure resident's room is clean and sanitized, 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. Civil penalty assessed as this violation was cited on 10/11/2023, within a 12 month period.

Exit interview conducted, and a copy of the report and appeal rights will be provided via email to Administrator.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240226134705
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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/22/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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R1's carpet was cleaned immediately during LPA's visit.
Licensee will conduct an in-service staff training regarding facility's expectation of cleanliness and sanitary conditions of resident's room.
Licensee is to notify LPA Yang of completion.
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Based on LPA's observation, Licensee did not comply to the section cited above as LPA observed R1's room to have an approximate two-feet brown stain next to R1's bed, used urinal bottle on top of night stand and red stains on linens which poses a potential risk to residents in care.
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$250 Repeat Violation Civil Penalty assessed
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/26/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240226134705

FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:VICKY CROSSFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 71DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Vicky CrossTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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2
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Staff did not properly manage incontinence care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an investigation regarding the allegation the department received. LPA met with Administrator, Vicky Cross, and explained the purpose of the visit.

During the investigation, LPA conducted a file review of R1's care plan and LIC 602. LPA obtained a photo of R1's bedroom.

Result of the investigation is as follow.

Please continue on LIC 9099-C (1)...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240226134705
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: 03/07/2024
NARRATIVE
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LIC 9099-C(1)...

Allegation: Staff did not properly manage incontinence care.
The department conducted file review for the allegation cited above. Based on R1's care plan, it revealed R1 is independent and self-care at toileting. Based on R1's LIC 602 PHYSICIAN'S REPORT, date of exam 10/29/2021, it revealed R1 does not have bowel and bladder impairment. Interview conducted on 03/07/2024 revealed that R1 likes to use a urinal bottle since it is easier than getting up to go to the bathroom.

Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint 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 report and appeal rights will be provided via email to Administrator.
 
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5