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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 08/14/2024
Date Signed: 08/14/2024 02:44:51 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
05/29/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240529145732
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: 63DATE:
08/14/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Allison LopezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Medication being administered late
INVESTIGATION FINDINGS:
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On 8/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding of the allegation cited above.

LPA met with Administrator, Allison Lopez, and explained the purpose of the visit.

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

The result of the investigation is as follow, please continue to LIC 9099-C.

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: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
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 2
Control Number 59-AS-20240529145732
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: 08/14/2024
NARRATIVE
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LIC 9099-C

Allegation: Medication being administered late
The Department conducted interviews and file review. Based on interview conducted with R1, it revealed that they are receiving muscle relaxers and anxiety medications late and was developing symptoms due to late administration of medications. R1 stated that based on physician orders, the anxiety medications are to be given by 9 AM for morning administration and by 6 PM for evening distribution. Interview reviewed R1 has received morning medications several times after 10 AM. Based on file review, it revealed that Lorazepam 0.5mg tablet was prescribed to R1, with physician orders, effective 5/23/2024, to be given one tablet by mouth twice a day as needed for anxiety. File review revealed that during complaint investigation, a new physician communication was faxed for all morning medications for 8:30 AM and all evening medication for 5:30 PM. File review revealed Lorazepam 0.5mg was prescribed as a PRN (pro re nata) medication not

Based on information obtained through file review and interview, 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 was left with Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2