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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 09/23/2024
Date Signed: 09/25/2024 01:49:46 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
09/10/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240910083137
FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:LOPEZ, ALLISONFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 69DATE:
09/23/2024
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Allison LopezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff did not dispense medications as prescribed
Facility staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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On 9/23/2024, Licenisng Program Analyst (LPA) Cassie Yang arrived to the facility unannounced at the facility to deliver the findings of the complaint above. LPA met with Administrator and explained the purpose of the visit.

The course of the investigation, LPA conducted interviews and file reviews.

The results 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: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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-20240910083137
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: 09/23/2024
NARRATIVE
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LIC 9099-C

Allegation: Facility staff did not dispense medications as prescribed.
The Department conducted a file review and interviews. Based on file review, it revealed that R1's physician has placed an order for Zyrtec 5 mg tablet daily. Interview conducted with R1 revealed that R1 has been receiving their Zyrtec medication in halves only. Interview conducted with Administrator revealed that Zyrtec comes in 10 mg tablet; therefore with the physician order of 5 mg, facility has been providing R1 with half Zyrtec tablet daily. Administrator stated that the following was addressed to R1's primary care physician which the physician order has now been changed to 10 mg which the facility is complying by providing R1 with a whole Zyrtec tablet.

Allegation: Facility staff did not safeguard resident's personal items.
The Department conducted interviews. Interview conducted with R1 revealed that facility safeguards R1's personal hygiene products. When R1 asked for more from facility staff, R1 was informed his personal supplies has been all used. Interview conducted with Administrator revealed that R1's personal hygiene products was not used by other residents in care. R1 receives personal hygiene shipments from R1's insurance, but the supplies has been placed on hold by a former facility staff. Administrator stated the order has since been placed for ongoing, and additionally, facility has ordered supplies for R1 until shipment arrives.

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

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2