342700186-9-6-2024-59-AS-KHOS-D97NXE-20240917105101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:59:12 PM

Unsubstantiated

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
10/17/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20231017104138

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:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Allison Lopez		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Facility is not kept free of pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to continue the investigation and deliver the findings. LPA met with Administrator, Allison Lopez, and explained the purpose of the visit.

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

The result of the investigation is as follow in LIC 9099-C.

Unsubstantiated

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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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-20231017104138

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: 09/06/2024

NARRATIVE

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LIC 9099-C

Allegation: Facility is not kept free of pests
The Department conducted interviews and file review. Based on interview with former Administrator on 10/27/2023, it revealed that facility does not have a cockroach and/or bedbug infestation but there has been a few occasion of bedbug detection in residents room. Interview revealed that it is unclear where and/or how bedbugs are entering the facility but Licensee is taking active actions wherever pest is detected by caregivers. Based on interview conducted with current Administrator conducted on 9/6/2024, it revealed facility had a recent bedbug treatment was conducted on 8/21/2024 for Room 47, Room 66 to Room 76 and no evidence of active bedbug was detected. Interview revealed that pest control treatments at the facility has been ongoing as needed. Interview further revealed that facility has been in contact with Aantex Pest Control for treatments for bedbugs the moment it is detected and additionally facility is being serviced for monthly pest control. File review revealed there are invoices from Aantex Pest Control for monthly service and/or bedbug treatments on 1/17/2024, 1/29/2024, 2/21/2024, 2/22/2024, 2/23/2024, 3/1/2024, 3/7/2024. Additionally, file review further revealed there are invoices from Clark Pest Control from 3/18/2024 and 6/19/2024 for bedbug treatments.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 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
10/17/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20231017104138

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:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Allison Lopez		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Staff do not provide proper medication assistance to resident in care
Resident's furniture is in disrepair
Residents in care are not provided housekeeping services
Resident in care has not been provided with a clean mattress

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with Administrator, Allison Lopez, and explained the purpose of the visit.

During the course of this investigation, LPA conducted file reviews, observations and interviews.

The result of the investigation are as follow in LIC 9099-C.

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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 59-AS-20231017104138

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: 09/06/2024

NARRATIVE

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LIC 9099-C(1)

Allegation: Staff do not provide proper medication assistance to resident in care
The Department conducted interviews and file reviews. Based on interview conducted with former Administrator on 10/27/2023, it revealed that there are two med techs on shift for AM and PM shift and one med tech for NOC shift. Administrator stated that when med tech calls off their shift, facility often utilize registry for staffing fill-ins. Interview further revealed that residents often complains that medications are not given in a timely manner but it is still given as prescribed such as "twice a day". Interview further revealed that medications that are prescribed "before meals" then it is prioritized to ensure facility is in compliance to medication orders. Interview conducted with current Administrator indicated that at this moment facility are staffed with two med techs and four caregivers per shift for AM and PM and then one med tech and one caregiver for NOC shift. Based on file review of staff schedule of July 2024, August 2024 and September 2024, it revealed that facility is staffed with with adequate med techs per day.

Allegation: Resident's furniture is in disrepair
The Department conducted interviews and observations for the following allegation. Interview conducted with former Administrator, it revealed that facility has a vacant room utilized for storage. Former Administrator stated that Licensee is often compliance with ordering extra mattress for emergency. Interview revealed that if a bed is dirty, facility will attempt on cleaning the mattress and if stain and/or the issue is not resolved then a new mattress is often replaced. Interview conducted with R1 revealed that R1 has never had an issue with getting a new mattress if needed. R1 stated that the facility is "really good" with replacing items. Interview conducted with R2 revealed that R2 does not have any furniture in disrepair but will notify Administrator if needed. Based on LPA's observation of ten residents room on 10/27/2023, 11/21/2023 and 8/14/2024, LPA observed no broken and/or disrepaired furnitures present.

Allegation: Residents in care are not provided housekeeping services
The Department conducted extensive interviews and file review. Interview conducted with former Administrator on 10/27/2023 revealed that there is one housekeeper at the moment but is in the process of hiring a second housekeeper. Interview revealed that all staff are taking a turn to clean residents room to fulfill the weekly housekeeping duties. Former Administrator stated that she has been assisting with cleaning rooms along with additional caregivers, the receptionist and maintenance supervisor. Interview conducted with S1 revealed that S1 has been cleaning rooms at the beginning of S1's shift although it is not S1's job duty. S1 stated that all staff are working together to keep the facility operating until vacancies are filled. File review conducted 7/12/2024 revealed that there are two housekeepers scheduled for the month of June 2024 with designed rooms to clean throughout the week. Interview conducted with Administrator on 9/6/2024, revealed there are now three housekeepers on schedule.

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: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 59-AS-20231017104138

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: 09/06/2024

NARRATIVE

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LIC 9099-C(2)

Allegation: Resident in care has not been provided with a clean mattress.
The Department conducted observations and interviews. Based on LPA's observation of ten residents room on 10/27/2023, 11/21/2023 and 8/14/2024, LPA did not observed any mattress that needed to be cleaned. Interview conducted with R1 revealed that R1 does not have an issue with R1's mattress. Interview conducted with R2 revealed that R2's mattress is "fine" and does not need a replacement. Interview conducted with R3 revealed that R3 is happy with everything in R3's room and does not need anything from the facility at this time. Interview conducted with R3 revealed that R3's mattress is clean and does not need a new mattress. Interview conducted with former Administrator on 10/27/2023 revealed that caregivers are responsible for making residents bed and if observed to be dirty, caregivers are to notify management team so deep cleaning can be conducted or a new mattress if needed.

Based on information obtained through interviews, file review and observations, 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 provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

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