342700186-10-2-2024-59-AS-KHOS-DAHHKP-20241029061617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 10/02/2024
Date Signed: 10/02/2024 03:48:00 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
09/30/2024 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20240930120610

FACILITY NAME:	WALNUT HOUSE		FACILITY NUMBER:	342700186
ADMINISTRATOR:	LOPEZ, ALLISON		FACILITY TYPE:	740
ADDRESS:	3401 WALNUT AVE		TELEPHONE:	(916) 483-6612
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	110	CENSUS: 72	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Allison Lopez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not intervening residents from being harassed by another resident in care.

INVESTIGATION FINDINGS:

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On 10/2/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open a complaint the Department received regarding the allegation cited above. LPA met with Administrator and explained the purpose of the visit.

During today's investigation, LPA conducted extensive interviews with Administrator, three residents and two facility staff.

The result of the investigation is as follow.

Continue on 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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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-20240930120610

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: 10/02/2024

NARRATIVE

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LIC 9099-C

Allegation: Staff are not intervening residents from being harassed by another resident in care.

The Department conducted interviews to investigate the following. Interviews conducted with R1 revealed that R1 has witnessed R2 and R3 yelling at each other often. R1 stated that R2 has been trying to antagonize R3 to trigger R3 to react. R1 stated staff often breaks up R2 and R3 if an altercation was to occur. Interview conducted with R2 revealed that facility had advised R2 to avoid going to a certain wing when trying to go to the lobby. R2 felt this is unfair as R2 is the only one being punished therefore, R2 does not follow the advisory. Interview conducted with S1 revealed that S1 has witnessed R2 and R3 yelling at each other. S1 intervened by separating the residents to opposite side of the common areas and de-escalating the situation. Interview conducted with Administrator revealed that Administrator had advised residents to avoid going a certain pathway to reduce chances of running into each other creating altercations. Administrator stated due to R3's current health condition, an eviction is not likely but facility will be implementing possible staggered meal times and/or additional caregiver supervision in the common area during meal times to minimize further altercations.

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 left at the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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