397005617-4-6-2022-27-AS-AJON-CD8S2E-20220406132924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005617
Report Date: 04/05/2022
Date Signed: 04/06/2022 01:32:14 PM

Document Has Been Signed on 04/06/2022 01:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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		FACILITY NUMBER:	397005617
ADMINISTRATOR:	MOSES WALTERS SR.		FACILITY TYPE:	735
ADDRESS:	2746 ABRUZZI COURT		TELEPHONE:	(510) 688-3552
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 4	DATE:	04/05/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Tannch Koayen		TIME COMPLETED:	02:20 PM

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Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct a case management visit. This visit is to deliver a civil penalty regarding substantiated serious bodily harm allegations. LPA met with Tannch Koayen /M. Walters and explained the purpose of the visit.

On August 6, 2021, the allegation, “Resident received a burn while in care” was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 85077(a) for not providing necessary personal assistance and care, as indicated in the needs and services plan, with activities of daily living including but not limited to dressing, eating, and bathing, etc.

The investigation determined that based on the incident report dated June 1, 2021, on Saturday May 29, 2021, at about 3:00 p.m., the facility staff smelled gas in the house, and everyone was removed from the house immediately. Pacific Gas and Electric Company (PG&E) was called immediately, and they shut off the gas. The PG&E technician then checked the house and noticed one of the cooker burners was not tight and they tightened it. The PG&E technician then turned the gas back on and reset all the settings (stove, water heater, and other). Per PG&E service note, the call was completed at 4:32 pm on May 29, 2021.

On Monday May 31, 2021, Staff was in the process of giving a Resident (R1) a bath in the tub. R1 reached for the faucet and turned it to the hot water.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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	FACILITY NUMBER: 397005617
	VISIT DATE: 04/05/2022

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The facility staff did not check the water temperature which resulted in R1 sustaining serious bodily injury by way of 2nd and 3rd degree burns. The hot water scalded both R1’s thighs and buttocks, less than 10 percent of R1’s body according to the medical records. 9-1-1 was called immediately, and R1 was taken to the local hospital. Due to the nature of the burns, R1 was transferred to a different hospital for continued care.

Medical records state that R1 arrived at an acute medical hospital on June 1, 2021, with 2nd and 3rd degree burns to 9 percent total body surface area (TBSA) to buttocks and Bilateral extremities (BLE). According to the Mayo Clinic, “third – degree burns extend into the fat layer that lies beneath the dermis…These types of burns usually require skin grafts for wound closure.” R1 was admitted to a hospital’s Intensive Care Unit for injuries sustained. During an Informal Office Meeting held on October 21, 2021, the licensee reported that clients had taken showers after the service call on May 31, 2021 but did not report the water to be any hotter than usual. Staff also did not notice the water any hotter than usual when washing dishes and doing other activities utilizing the facility water after the service call and prior to the incident with R1.

On August 6, 2021, the licensee was informed that a civil penalty of $10,000 may be assessed based on H&S Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code §15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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	FACILITY NUMBER: 397005617
	VISIT DATE: 04/05/2022

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Today, 4/5/2022 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. A copy of the LIC 421D was given to
(Tannch Koayen) and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided.
(Tannch Koayen) signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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