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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 01/21/2025
Date Signed: 01/21/2025 01:33:30 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
12/26/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20241226151401
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: 72DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Allison LopezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff did not provide adequate food service to resident in care.
Facility staff did not address residents being left in soiled clothing in a timely manner.
INVESTIGATION FINDINGS:
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On January 21, 2025 at approximately 11:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Walnut House for the purpose of conducting an investigation. LPA was greeted at the door by Administrator, Allison Lopez, and was granted access into the home.

During the course of the investigation, LPA interviewed staff, and the former resident. In addition, LPA reviewed resident files and facility file. LPA made attempts to interview Witness #1 but was unsuccessful.

Complaint alleges that Facility staff did not provide adequate food service to resident in care. Based on interviews that were conducted, LPA could not prove or disprove that the allegation occurred. LPA received inconsistent statements. Furthermore, during an interview with Resident #1, LPA learned of no concerns as it relates to the food service at the facility. LPA could not corroborate the allegation. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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-20241226151401
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: 01/21/2025
NARRATIVE
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Complaint alleges Facility staff did not address residents being left in soiled clothing in a timely manner. Based on interviews that were conducted, LPA could not prove or disprove that the allegation occurred. LPA received inconsistent statements. During the incident in question, LPA learned that Resident #1 was preoccupied with retrieving the cell phone, and did not summon for help as the resident did not want help changing out of clothes as the resident can perform that function. LPA reviewed the Service Plan which indicated that the resident needed minimal assistance with toileting and dressing. LPA could not corroborate the allegation.

A finding that the complaint allegations of: Facility staff did not provide adequate food service to resident in care and Facility staff did not address residents being left in soiled clothing in a timely manner are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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
12/26/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20241226151401

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: 72DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Allison LopezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff do not ensure that residents' medications are stored locked and inaccessible to residents.
INVESTIGATION FINDINGS:
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On January 21, 2025 at approximately 11:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Walnut House for the purpose of conducting an investigation. LPA was greeted at the door by Administrator, Allison Lopez, and was granted access into the home.

During the course of the investigation, LPA interviewed staff, and the former resident. In addition, LPA reviewed resident files and facility file. LPA made attempts to interview Witness #1 but was unsuccessful.

Complaint alleges that Facility staff do not ensure that residents' medications are stored locked and inaccessible to residents. Based on an interview with the Administrator, the preponderance of evidence standard has been met. LPA learned that there were medications that were left accessible in a former resident room. (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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-20241226151401
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: 01/21/2025
NARRATIVE
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Administrator acknowledged of being aware of this because of a bad Yelp review. Administrator retrieved the medication from the former residents room (See LIC 9099D). LPA educated the Administrator on the importance of ensuring that all residents medications are kept locked and secured.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20241226151401
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2025
Section Cited
CCR
87465(h)(2)
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87465(h)(2) Incidental Medical and Dental Care:

(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement was not met as evidenced by:
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Licensee/Administrator shall fill out an LIC 9098-Self Certification understanding of the regualtion. Licensee/Administrator shall conduct staff training and provide proof of staff training. Licensee/Administrator shall provide a statement on how future compliance will be met.
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Based on an interview with the Administrator, Administrator acknowledged that after seeing a bad Yelp review, medications were found in the former residents room which presents a potential health, safety and personal rights risk to the residents in care.
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POC Due date:

January 28, 2025.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5