342700186-7-24-2024-59-AS-KHOS-D8AHXH-20240819063508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 07/24/2024
Date Signed: 07/24/2024 01:45:58 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
09/27/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230927082132

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: 65	DATE:	07/24/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Allison Lopez		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff does not meet resident's dental care needs.
Staff does not allow resident to select the clothes they wear.
Staff does not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to continue an investigation and delivered the findings of the allegations cited above. LPA met with Interim Adminstrator, Allison Lopez, and explained the purpose of the visit.

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

The result of the allegation cited above is as follow.

Please continue on 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: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

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-20230927082132

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: 07/24/2024

NARRATIVE

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LIC 9099(C)(1)
Allegation: Staff does not meet resident's dental care needs.
The Department conducted file review and interviews for the following allegation. Based on interview conducted with former Administrator on 9/28/2023 and Interim Administrator on 07/03/2024, majority residents in care are independent with dental care hygiene. Interview conducted with R1 indicated that R1 brushes their own teeth and does not need assistance from staff. R1 indicated that if in dental pain R1 is to notify R1's responsible party and/or notify Administrator for a dental appointment. File review for R1's service plan revealed R1 is independent/self care with dental needs. Interview conducted with R2 indicated that R2 is responsible for their own dental care and does not need staff to assist with brushing. R2 gets reminders from care staff to brush their teeth in the morning and night. File review for R2's service plan revealed R2 needs verbal cueing with dental care. Interview conducted with R3 indicated that R3 brushes their own teeth and does not need assistance from staff. File review for R1's service plan revealed R3 is independent/self care with dental needs. Interview conducted with R4 indicated that R4 brushes their own teeth and does not need assistance from staff. File review for R4's service plan revealed R4 wears dentures and is independent/self care with dental needs. Interview conducted with R5 indicated that R5 can brush own teeth without assistance. File review for R5's service plan revealed R5 is independent/self care with dental needs. Interview conducted with R6 indicated that R6 likes to be independent and can do most activities of daily living on their own, including dental care needs. File review for R6's service plan revealed R6 is independent/self care with dental needs. Based on information obtained through file review and interviews, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Allegation: Staff does not allow resident to select the clothes they wear.
The Department conduct extensive interviews. Interview conducted with R1 revealed that R1 feels like they are able to select their own clothing to wear. R1 stated staff are forcing them to wear other clothing. Interview conducted with R2 revealed that R2 wears whatever they want without staff's advisory and/or enforcement. R2 stated they have never experienced an issue with selecting own clothing. Based on interview conducted with R3 revealed that R3 has never been told what to wear. Interview conducted with R4, R5 and R6 revealed they do not have an issue with selecting own clothing at the facility. Based on information obtained through interviews, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Please continue to 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: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230927082132

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: 07/24/2024

NARRATIVE

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LIC 9099(C)(2)

Allegation: Staff does not treat resident with dignity and respect.
The Department conduct extensive interviews. Interview conducted with R1 revealed that R1 feels safe at the facility. R1 stated staff are helpful and does not have issue regarding their care and supervision. Interview conducted with R2 revealed that R2 enjoys the help of the facility staff. R2 is able to get their assistance whenever asked and staff are willingly. Interview conducted with R3 revealed that R3 does not feel disrespected by facility staff when asked for care. Interview conducted with R4 revealed that facility staff treats R4 with dignity and respect and R4 cannot recall being treated in a poor manner. Based on interview conducted with R5 revealed that R5 believes facility is trying their best to accommodate to all residents in care. R5 stated that R5 feels respected and is comfortable speaking to Administrator if there is an issue. Interview conducted with R6 revealed that R6 has been living at the facility for over three years and enjoys the facility. R6 stated that staff accommodates to their needs and has been helpful.

Based on information obtained through interviews, the allegation listed above is 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 was provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC9099 (FAS) - (06/04)

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