<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700580
Report Date: 08/18/2022
Date Signed: 08/18/2022 03:59:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220617152213
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 3FACILITY NUMBER:
392700580
ADMINISTRATOR:CRISTOPHER WALTERSFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:4CENSUS: 4DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Blama KorhaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is denying residents access to food.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced facility visit on 08/18/2022 at 2:00pm to deliver complaint findings. LPA Pascua met with Caregiver, Blama Korha and explained the purpose of the visit. LPA Pascua asked Caregiver, Korha to notify the administrator to let them know that CCL was present at this time.
Allegation: Facility is denying residents access to food.
Based on an interview with Caregiver, Joseph Nimeme, it was learned that a representative from Valley Mountain Regional Center conducted an unannounced visit to this facility and found that the pantry was locked. Staff admitted that the pantry was locked because the facility was notified by the doctor and family member to help R1 lose weight because of his recent weight gain. Staff stated that there were keys available for other residents to take and open up the pantry. LPA Pascua also observed that this was the only pantry available for residents to have access to non-perishable food supply.
As a result of this investigation, this LPA finds the allegation to be SUBSTANTIATED-A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were on 9099-D, per Title 22 Regulations, Division 6 and/or Health and Safety Code.
Exit interview was conducted, a copy of this report and appeal rights were left with Caregiver, Joseph Nimeme.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220617152213

FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 3FACILITY NUMBER:
392700580
ADMINISTRATOR:CRISTOPHER WALTERSFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:4CENSUS: 3DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joseph NimeneTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not maintaining current resident files.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced facility visit on 08/18/2022 to deliver complaint findings. LPA Pascua met with Caregiver, Joseph Nimeme and explained the purpose of the visit. LPA Pascua asked Caregiver, Nimene to notify the administrator to let them know that CCL was present at this time.
Allegation: Facility is not maintaining current resident files.
During an interview with the staff, staff stated that R1's family member and the primary care physican have requested that R1 needed to change his diet due to his weight gain. Based on facility records, LPA Pascua found that R1 did not have a special diet in their file. Furthermore, R1’s Individual’s Program Plan did not recognize R1’s weight to be an issue. The facility did not have any additional documentation from R1's primary care physician regarding any changes to R1's diet. LPA Pascua also reviewed 3 out of 3 resident P&I funds. All 3 files were completed with all required forms and signatures. Based on the information provided through interviews and records review, It is unclear if the facility has maintained current resident files.
As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.
An Exit interview was conducted, and a copy of this report were left with Caregiver, Joseph Nimeme.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220617152213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 3
FACILITY NUMBER: 392700580
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2022
Section Cited
CCR
85076(d)(1)
1
2
3
4
5
6
7
85076(d)(1) Food Service
(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will ensure that the kitchen pantry closet where snacks are kept is unlocked for the clients.

***POC corrected and cleared during today's visit. Lock was removed from the kitchen pantry.
8
9
10
11
12
13
14
The facility locked non-perishable food supply in pantry not allowing immediate access for residents. Based on observation, and interviews licensee locked the facility pantry which did not ensure immediate access to food supply. This poses a potential health, safety, personal rights risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3