366424264-1-23-2024-18-AS-JDHS-CZXQZJ-20240129113649

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366424264
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:39:25 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2020 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20200717095959

FACILITY NAME:	WALNUT SENIOR HOME		FACILITY NUMBER:	366424264
ADMINISTRATOR:	KAUR, GULVARG		FACILITY TYPE:	740
ADDRESS:	291 E. WALNUT AVE.		TELEPHONE:	(909) 877-5675
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	6	CENSUS: 4	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Administrator, Gulvarg "Maya" Kaur		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff did not assist resident with transferring out of bed
Facility staff did not follow resident's care plan
Facility staff did not allow resident to have private phone calls
Facility staff spoke inappropriately to resident
Facility staff did not assist resident with hygiene needs
Facility staff did not seek medical attention in a timely manner
Facility staff did not ensure that resident drank enough fluids

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to deliver findings on a complaint investigation regarding the allegations listed above. LPA met with Licensee/ Administrator, Administrator, Gulvarg "Maya" Kaur and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review.
On 07/17/2020, Community Care Licensing (CCL) received a complaint that alleged facility staff did not assist resident with transferring out of bed, facility staff did not follow resident’s care plan, facility staff did not allow resident to have private phone calls, facility staff spoke inappropriately to residents, facility staff did not assist residents with hygiene needs, facility staff did not seek medical attention in a timely manner, and facility staff did not ensure that resident drank enough fluids.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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 18-AS-20200717095959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WALNUT SENIOR HOME	FACILITY NUMBER: 366424264
	VISIT DATE: 01/23/2024

NARRATIVE

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Information obtained from Administrator Kaur stated the staff that worked at the facility in 2020 were no longer employed and Administrator did not have contact information. It was also advised that Administrator discarded staff and residents’ files that were older than 3 years. No residents that were placed in 2020 are currently at the facility. During the investigation, LPA attempted to contact Resident 1 (R1), and it was revealed that the R1 had passed away on 12/04/2022.

In regards to the facility staff did not follow resident's care plan, it was alleged that the facility did not follow the care plan provided to the facility. Administrator stated that they followed the care plan, but there was another care plan that R1’s Responsible Party wanted the facility to follow on top of the care plan agreed by facility representatives and Responsible Party. Administrator stated due to Covid restrictions and the extreme nature of the care plan, they presented R1 with an eviction notice, which was served on 05/17/2020.

In regards to the allegations that the facility staff are not allowing R1 to have private phone calls and facility staff spoke inappropriately to resident. It was reported that staff would stand at the bed side R1 while they spoke on the phone and interrupt their phone calls. This allegation was not able to be corroborated or disputed due to R1 passing away and no staff member that were able to be interviewed regarding their 2020 employment. During the course of the interview, Administrator denied the allegations.

In regards to the allegation that the facility staff did not assist resident with hygiene needs, it was reported that Resident needed additional assistance with ambulating and hygiene needs due to Resident #1 being blind. Additional details stated that facility did not ensure R1’s toenails were cut. The department did not receive any proof or documentation that the allegations occurred. During the course of the interview, Administrator denied the allegations.

Based on the inability to interview pertinent residents, staff, and additional witnesses, the allegations listed above are deemed unsubstantiated at this time. 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.

An exit interview was conducted, an LIC 811, a copy of this report was provided to the Licensee, Gulvarg "Maya" Kaur as evidenced by her signature.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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