342700186-7-3-2024-59-AS-APEZ-D79MV8-20240717095618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:31:53 PM

Unfounded

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
03/29/2024 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20240329103627

FACILITY NAME:	WALNUT HOUSE		FACILITY NUMBER:	342700186
ADMINISTRATOR:	VICKY CROSS		FACILITY TYPE:	740
ADDRESS:	3401 WALNUT AVE		TELEPHONE:	(916) 483-6612
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	110	CENSUS: 66	DATE:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Allison Lopez		TIME COMPLETED:	04:27 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illegal eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cassie Yang unannounced at the facility to deliver the finding of the allegation cited above. LPA met with Interim Administrator and explained the purpose of the visit.

During the course of the investigation, LPA conducted extensive interviews and file review.

Result is as follow, please continue LIC 9099-C(1).

Unfounded

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: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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 3

Control Number 59-AS-20240329103627

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: 07/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

**LIC 9099-C (1)**
Allegation: Illegal eviction

The Department conducted file review and interviews. File review revealed a 30 day eviction letter dated March 1, 2024 was provided with effective date of April 2, 2024. File review revealed that R1 was evicted due to change of condition. It was determined that R1 has a need not previously identified as reappraisal was conducted on January 29, 2024 by Facility Nurse. Facility Nurse believe that the facility is not appropriate for R1 due to constant confusion of exit seeking.

Care notes revealed on 3/25/2023, R1 was trying to get out of the facility to check R1's car in the parking lot, R1 was then redirected back to the room. On 7/19/2023, R1 was attempting to leave the facility through the front door at approximately 2AM. On 7/31/2023, R1 was confused and wanted to take a cart to unload things from his truck and R1 was trying to get out of the facility to look for the truck. On 8/6/2023, R1 was walking around the facility to get out. On 9/6/2023 at approximately 11PM, R1 was walking around and stated R1 had to go free the cows. On 11/4/2023, R1 was seeking exit at 2AM through the front door and then at approximately 3:30AM R1 was exit seeking through the sliding delivery door. On 12/4/2023 at approximately 1:30PM R1 gathered notebooks and informed staff R1 was looking for a bus that will take R1 home. R1 was then redirected back to the room. On 12/14/2023, R1 was very confused and was packing up personal belongings from R1's room and informed staff that someone was waiting for R1 in the car. On 12/25/2023, R1 was waiting to leave the facility and informed staff R1's family took all R1's money and that R1 wants to go get it back. On 12/26/2023, R1 was walking around all night in the living room and informed staff R1 had to leave for work.

File review revealed in preplacement appraisal conducted for R1 on 12/10/2019, on page 2 under "Services Needed- Other Services Needed not identified above" it was marked no. Resident Appraisal conducted on 1/29/2024, on page 2 under "Services Needed- Other Services Needed not identified above" it was marked "yes" with the comment of "HX of exit seeking, and HX of sexually inappropriate behavior requiring frequent checks and oversight".

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: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240329103627

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: 07/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

*** LIC 9099-C(2)***

File review of R1's Service Plan conducted on 4/29/2022 revealed R1 scored zero (0) for wandering and elopement, Needs/Details: independent, no assistance R1's Service Plan conducted on 9/4/2023 revealed R1 scored four (4) for wandering and elopement, Needs/Details: Occasional, routine support with special care needs. R1's Service Plan conducted on 12/4/2023 revealed R1 scored nine (9) for wandering and elopement, Needs/Details: Occasional redirection if wandering or approaching exits.

Interview conducted with S1 revealed S1 was R1's caregiver and recalled R1 being a "sweet resident" but would make comments to other residents. S1 stated R1 wandered the facility and would pack his belongings saying R1 is going to war. S1 stated in another incident, R1 started packing picture frames and informed staff R1 was going home. Interview further revealed that S1 has seen R1 exit seeking in a handful of occasions but R1 was easy to redirect back to room. R1's exit seeking was mainly at night when R1 is sundowning. Interview conducted with S2 revealed R1 was found near the front door, when asked what was R1 doing, R1 stated R1 was waiting for a ride to leave. S2 stated R1 was good with redirection.

Based on information obtained through file review and interviews, the allegations listed above are 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 the report and appeal rights was left with Interim Administrator.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3