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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 02/11/2025
Date Signed: 02/25/2025 03:25:14 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
12/27/2024 and conducted by Evaluator Farhaan Sarangi
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20241227120434
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: 69DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Med Tech, Kim TaylorTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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**report ammended**
Staff did not ensure that a resident was provided meals and water.
Staff did not ensure that resident's clothing was changed.
INVESTIGATION FINDINGS:
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*** Report amended Additional report for amended findings***
.On February 11, 2025 at approximately 08:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Walnut House for the purpose of delivering complaint findings. LPA was greeted at the door by Med Tech, Kim Taylor, and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff members and conducted a Collateral Interview with Resident #1. In addition, LPA reviewed the facility files, resident file and medical records.

Complaint alleges that Staff did not prevent a resident from developing pressure injuries while in care and Staff left a resident on a toilet for a long period of time. Based on interviews that were conducted, resident files reviewed, and medical records reviewed, LPA could not prove or disprove the allegations occurred.***This finding is amended. ***
(Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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 2
Control Number 59-AS-20241227120434
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: 02/11/2025
NARRATIVE
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LPA reviewed the Service Plan and observed that the resident was on Level II care that required no assistance as it relates to transfers and mobility. In addition, the Service Plan was signed and dated on December 10, 2024, by the Responsible Party. LPA reviewed the call bell log for the date in question and observed that the resident did not press the call pendent or alert staff. During a review of the Medical Records on January 22, 2025, LPA learned that the resident was on the commode for 7 hours. However, the hospital could not determine what caused the resident to be on the commode for that long. On January 21, 2025, LPA conducted a collateral interview with Resident #1 but could not obtain additional information as to what occurred. During interviews, LPA received inconsistent statements as it relates to the allegations. LPA could not corroborate the allegations.

Complaint alleges Staff did not ensure that a resident was provided meals and water. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. Furthermore, during interviewing, LPA learned of no concerns as it relates to the food service at the facility. LPA could not corroborate the allegation.

Complaint alleges Staff did not ensure that resident's clothing was changed. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. Furthermore, during interviewing, LPA learned of no concerns as it relates to the changing of resident’s clothing. LPA could not corroborate the allegation.

A finding that the complaint allegations of: Staff did not prevent a resident from developing pressure injuries while in care, Staff left a resident on a toilet for a long period of time, Staff did not ensure that a resident was provided meals and water, Staff did not ensure that resident's clothing was changed 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 Med Tech.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2