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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 12/30/2020
Date Signed: 11/05/2021 02:40:41 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
05/15/2020 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200515160116
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: 56DATE:
12/30/2020
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lacy Berry, Administrator TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to safeguard medications.
Facility staff's lack of care and supervision resulted in resident being hospitalized.
Facility staff’s lack of care and supervision contributed to resident’s death.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This report was amended on 11/5/2021, on (1) 9099-D page only, so that (2) citations that were originally issued and subsequently dismissed, due to an incorrect regulation or health and safety code used, can be re-issued under the correct Title 22 Regulation. There were no other changes made to this original report issued on 12/30/2020. Licensing Program Analyst (LPA) Sabrina Calzada met with Administrator, Lacy Berry, on 11/5/2021 at the facility to review the amended 9099-D page and obtain signatures. **

Licensing Program Analyst (LPA) Sabrina Calzada conducted a tele-visit on 12/30/2020, due to Covid-19 precautionary measures in place, to deliver findings to a complaint received by the department on 5/15//2020. LPA met with Lacy Berry, Administrator, and explained purpose of today's tele-visit.

During the course of the investigation, the department interviewed multiple facility staff members, attending Intensive Care Unit (ICU) physician and Toxicologist at the hospital, resident’s family members and others. The department also reviewed documentation including, but not limited to, resident’s medical records, Individual Plan of Care, narrative charting notes, fax correspondences with physicians, discharge paperwork for mental health services received, and facility medication records.

The results of the investigation are as follows:

Allegation: Facility failed to safeguard resident's medications. On or around 5/9/2020, resident's family members visited resident at the facility and brought resident 3 gift bags which contained gifts, food, Tylenol and Pepto Bismol. The bags were given to the front desk receptionist from the main door since only outside visiting was allowed per Covid-19 pre-cautionary measures. It is uncertain if the family told staff that there were medications in the bag. Family members stated that it was it was their expectation
cont on 9099C(1)..
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
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 6
Control Number 27-AS-20200515160116
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: WALNUT HOUSE
FACILITY NUMBER: 342700186
VISIT DATE: 12/30/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099C(1)..that packages are checked when dropped off, based on prior experiences. Family members indicated they recall staff (S1) stating that S1 would take the bags to R1’s room. S1 was interviewed and stated she only checked one of the bags, which had a black computer tablet and candy. Staff interviews were conducted which provided conflicting information. Some staff indicated that staff are responsible for checking gifts or asking the contents of the package and logging packages to ensure there are no hazardous items while some staff stated that packages are only checked if they are notified by family or suspect something hazardous in the package. Administrators and staff were unable to provide a written policy.

Based on medical records reviewed, On 5/10/2020, R1 was admitted to the hospital with the initial complaint of a stroke, but after further testing, resident was diagnosed with liver failure. Resident's labs were drawn on 05/11/2020 which showed resident’s Tylenol to be at 265 microgram/ milliliters. The normal range for Tylenol is 0-30 microgram/milliliters. Based on interviews conducted, if R1’s labs would had been drawn at the time of arrival, it would have been significantly higher but since Tylenol metabolizes, the level was lower at the time the blood was drawn. Interviews indicated R1 had an acute ingestion of taking over 100 pills at one time.

Based on toxicologist interviewed, it was confirmed that R1 had elevated Tylenol levels and explained that there were two possible scenarios that could have occurred; either R1 ingested multiple Tylenol pills over multiple days or R1 had a "massive overdose of Tylenol more than 24 hours ago". R1’s medication log was obtained from Walnut House for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days for the month of May. It is unclear how resident obtained a large quantity and had an overdose of Tylenol. Resident’s physician report dated 2/20/2019 documents that resident is “unable to administer own prescription medications and is unable to administer own PRN medication”. Additionally, PRN Medication Statement dated 4/19/2019 indicates that resident is “unable to determine his/her own need but is able to clearly communicate his/her symptoms for a non-prescription PRN medication(s)”.

Based on information obtained, the department 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.

cont on 9099C(2)..
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20200515160116
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: WALNUT HOUSE
FACILITY NUMBER: 342700186
VISIT DATE: 12/30/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099C(2)..
Allegation: Facility staff's lack of care and supervision resulted in resident being hospitalized.

On 5/10/2020, an alternative emergency ambulance medical services was dispatched to Walnut House (see 809 dated 12/30/2020 for citation issued). It was reported that resident had an altered level of consciousness and was unable to follow basic commands. Resident appeared to have slurred speech and right facial dropping. Resident was transported to the hospital with an initial complaint of stroke. During the course of the hospitalization, resident was admitted to the intensive care unit (ICU) for acute toxic metabolic encephalopathy, decompensated liver failure secondary to Tylenol overdose, and disseminated intravascular coagulation (DIC) due to acute acetaminophen toxicity. Resident underwent multi organ failure and was placed on a mechanical ventilation.

Resident’s physician’s report dated 2/20/2019 notes that the facility is responsible for managing and administering prescription medication and PRN medication. Resident’s medication log was reviewed for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days of the month of May.

Based on information obtained, the department 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.

Allegation: Facility staff’s lack of care and supervision contributed to resident’s death.

Hospital medical records document that resident passed away on 6/8/2020 at 1210 hours. The immediate cause of death is listed as Cardiorespiratory arrest. Resident had renal failure and liver failure. Hypernatremia and Dementia were listed as other significant conditions that contributed to the death but not related to the cause of death. Hospital Toxicologist stated that resident’s cause of death was multi-organ failure and stated the overdose of Tylenol was the primary reason for the multi-organ failure. Toxicologist indicated that it was clear that resident had ingested a high amount of Tylenol and explained that there were two possible scenarios of how it occurred- either resident ingested multiple Tylenol pills over multiple days or resident had a “massive overdose of Tylenol more than 24 hours ago”. Toxicologist further stated that if an individual is seen within 80 hours of ingesting
cont on 9099C(3)..
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20200515160116
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: WALNUT HOUSE
FACILITY NUMBER: 342700186
VISIT DATE: 12/30/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099C(3).. a high amount of Tylenol, it would be easier to determine if they could be treated. By the time resident was seen, it was over 80 hours and it was difficult to predict if resident could be treated or if they was going to recover. Additionally, facility did not communicate to the Emergency Medical Technicians (EMT’s) that resident had a history of depression and suicide attempts by overdosing on medications, which affected the approach and timing of measurements taken once resident was admitted to the emergency room. Facility told the EMT's that resident was believed to have had a stroke.

Sacramento Coroner Investigator ruled resident’s death as a suicide that was caused by ingesting a lethal amount of medication.

Resident’s physician’s report dated 2/20/2019 notes that the facility is responsible for managing and administering prescription medication and PRN medication. Resident’s medication log was reviewed for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days of the month of May.

Based on information obtained, the department 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.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following three (3) citations are being issued. Failure to comply with the Plan of Corrections by the noted due date may result in a penalty(ies) being assessed.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.


Exit interview. Copy of report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20200515160116
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: WALNUT HOUSE
FACILITY NUMBER: 342700186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2021
Section Cited
CCR
87465(h)(1)(B)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility began logging all incoming packages on/around 5/16/2020 following incident, provided training at that time, and established a written procedure of checking all incoming packages, including gifts. Administrator stated all staff are currently following this protocol. Administrator agrees to provide documentation of training agenda/attendees and also submit a written policy to CCLD by 1/8/2021.
8
9
10
11
12
13
14
Based on interviews conducted, the Licensee did not ensure that all packages dropped off on 5/9/2020 were screened prior to giving to resident (R1) to ensure there were no hazardous items inside, including Tylenol medication. Receptionist stated that the contents of only 1 of 3 bags, which was the bag without tissue paper, was viewed prior to giving to resident, which posed an immediate health and safety risk to resident in care.
8
9
10
11
12
13
14
Type A
01/08/2021
Section Cited
HSC
1569.312(e)
1
2
3
4
5
6
7
§1569.312 Basic services requirements (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility created a “Resident Change in Condition Form” on/around October 2020, to be used by both caregivers and Shift Managers and other staff when observing change(s) in condition in a resident. . Administrator agrees to conduct another staff training to remind staff to use the form, contact appropriate parties when a change in condition is observed, and update the care plan accordingly. Documentation of training agenda/attendees to be provided to CCLD by 1/8/2021.
8
9
10
11
12
13
14
Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff was regularly “monitoring resident’s (R1) emotion, frustration or anxiety” resulting from resident’s diagnosis of depression and keeping a daily log to document resident’s needs and care, as noted on resident’s plan of care dated 10/31/2019, which posed an immediate health and safety risk to resident.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 27-AS-20200515160116
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: WALNUT HOUSE
FACILITY NUMBER: 342700186
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/08/2021
Section Cited
CCR
87465(a)(2)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care
a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to conduct staff training on communicating client medical history and/or recent change in conditions, as noted on most recent care plan, to EMT. Administrator will discuss how to document essential medical information to be given to EMT's amd provide a form if created. Documenattion of training agenda/attendees to be provided to CCLD by fax by 1/8/2021.
8
9
10
11
12
13
14
Based on interviews conducted and documentation reviewed, the Licensee did not ensure that essential medical information, including resident's (R1) history of attempted suicide with medications, was conveyed to emergency medical services personnel, on 5/10/2020, which posed an immediate health and safety risk to resident 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.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 6