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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:25:43 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
11/13/2023 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20231113145847
FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:LACY BERRYFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 71DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Allison LopezTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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8
9
Staff do not assist residents with dental hygiene
Staff do not safeguard residents personal belongings
INVESTIGATION FINDINGS:
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3
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5
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7
8
9
10
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12
13
On 10/29/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to investigate and deliver the findings of the allegations cited above. LPA met with Administrator and explained the purpose of the visit.

During the course of the investigation, the Department conducted intensive file reviews, interviews and observations.

The result of the allegations are as follow, please continue on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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-20231113145847
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: 10/29/2024
NARRATIVE
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LIC 9099-C

Allegation: Staff do not assist residents with dental hygiene

Interviews and file review was conducted for the following allegation. File review of R1’s service plan and R8’s service plan revealed R1 and R8 has maximum assist for dental care. Interview conducted with Administrator on 11/21/2023 revealed R1’s responsible party has not visit R1 often due to responsible parties living out of town and/or state. Administrator stated R1’s care requires dental assistance which facility complies. Interview conducted with R1 on 11/21/2023 revealed “care is really good”. R1 stated there is no issues with staff as all caregivers are nice and helps R1 as needed. Interview conducted with R8 revealed that R8 is not sure who their caregiver is. R8 indicated they are unsure if staff assist with dental care. Interview conducted with S1, it revealed that S1 is R8’s caretaker for the shift. S1 stated S1 assisted R8 with bowel incontinence care and additionally with morning dental care. File review of R1’s physician report revealed R1 has mild cognitive impairment but is disoriented to time. File review of R8’s physician report revealed R8 has vascular dementia and is often confused. The allegation is unsubstantiated.

Allegation: Staff do not safeguard resident’s personal belongings.

The Department conducted interviews and inspection of the following allegation. Interview conducted with Administrator on 11/21/2023 revealed facility does not handle residents' cash resources. Based on observation of Room 14, Room 23, Room 41, Room 44, Room 47, Room 52, Room 60, and Room 64, it revealed all rooms have a lock on the doorknob to ensure safeguarding. Based on observation, it revealed resident locks are to be “dummy locks” which can be unlocked with a coin. Interview conducted with R1 revealed R1 is not sure if any clothing is missing as R1 has not checked. Interview conducted with current Administrator revealed there has been some complaints of missing clothings but when investigated, clothings are still folded in the laundry room. Observation revealed laundry room has a code lock and only accessible to staff. At this time, allegation is unsubstantiated.

With the information obtained, LPA found the allegations 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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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
11/13/2023 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20231113145847

FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:LACY BERRYFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 71DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Allison LopezTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure residents room is kept in safe, clean, sanitary conditions and in good repair at all times
Staff do not ensure residents have access to clean linens
Staff do not ensure residents has sufficient storage space
Staff do not ensure residents wheelchair is in good repair
Staff do not ensure residents room is free of malodors
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/29/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to investigate and deliver the findings of the allegations cited above. LPA met with Administrator and explained the purpose of the visit.

During the course of the investigation, the Department conducted intensive file reviews, interviews and observations.

The result of the allegations are as follow, please continue on LIC 9099-C(1).
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: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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-20231113145847
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: 10/29/2024
NARRATIVE
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LIC 9099-C (1)

Allegation: Staff do not ensure residents room is kept in safe clean, sanitary condition and in good repair at all times.

The Department conducted file review and interviews. File review revealed that there is housekeeping once a week, and additional at an extra charge. Interview conducted with R1 revealed R1’s room does get clean weekly, but caregiver assist with daily trash and bed making in the morning. R1 stated staff is very nice and helpful. Interview conducted with R3 revealed that staff are good with assisting as needed. R3 stated there are times R3 informed staff to help clean the trash. Interview conducted with R6 revealed R6 is very particular with housekeeping. R6 stated there is no concerns regarding getting bedroom clean in a timely manner however, R6 would like caregiver to check in periodically for garbage check. Interview conducted with R7 revealed R7 does not have concerns regarding housekeeping since R7 can be minimal and clean. Interview conducted with Administrator on 11/21/2023 revealed that caregivers are to assist with day-to-day cleaning such as emptying the trash and making the bed whereas housekeeping assist with the deep cleaning such as vacuuming and bathroom cleaning. Therefore, allegation is unfounded.

Allegation: Staff do not ensure residents have access to clean linens.

Based on observation conducted for Room 14, Room 23, Room 41, Room 44, Room 47, Room 52, Room 60, and Room 64, it revealed facility has clean linen present. Observation conducted of facility spare linens, it revealed facility has ample supply of clean linen, including blankets, bed sheets, pillowcases, and bath towels. The linen observed to be in good repair. Based on interview conducted with current Administrator on 10/29/2024, it revealed during resident’s housekeeping day, linens are to be removed and transported to the laundry room for washing. Based on interview conducted with S1 revealed if residents had an incontinence accident on the linen, caregivers would replace the linen with a clean set. Based on interview conducted with R1 on 11/21/2023, it revealed that R1 is often in bed but if needed staff will change the linens for R1. Therefore, the allegation is unfounded.

Please continue to LIC 9099-C(2)

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

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20231113145847
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: 10/29/2024
NARRATIVE
1
2
3
4
5
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LIC 9099-C(2)

Allegation: Staff do not ensure residents has sufficient storage space

The Department conducted an inspection of the following allegation. Based on observation of Room 14, Room 23, Room 41, Room 44, Room 47, Room 52, Room 60, and Room 64, it revealed facility has met the required resident personal accommodation of portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided. Therefore, allegation is unfounded.

Allegation: Staff do not ensure residents wheelchair is in good repair.

The Department conducted extensive interviews. Based on interview conducted with R1 revealed R1’s wheelchair has been fine and no concerns. Based on interview conducted with Administrator on 11/21/2023 revealed facility does not provide residents in care with wheelchairs but if there is a surplus at the facility, facility will lend a spare to residents in care. Interview conducted on 10/29/2024 with current Administrator revealed that it is not often for work orders to be placed for wheelchairs. If needed and brought to attention by staff and/or residents in care, facility will contact wheelchair company for repairs. Administrator stated she assisted R9 with physician order and insurance order for a new wheelchair as R9’s wheelchair was having complications. Interview conducted with R9 revealed facility assisted R9 with new wheelchair order. Allegation is unfounded.

Allegation: Staff do not ensure residents room is free of malodors

The Department conducted an inspection of the following allegation. Based on observation of Room 14, Room 23, Room 41, Room 44, Room 47, Room 52, Room 60, and Room 64, it revealed the rooms observed did not have a malodor and/or remains free of odors from incontinence. Based on observation of the facility conducted on 11/21/2023 and 10/29/2024, it revealed no concerns of malodor. Therefore, allegation is unfounded.

Based on information obtained, 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: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5