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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:27:55 PM

Substantiated


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 Kevin Mknelly
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: 70DATE:
02/25/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Allison LopezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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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.
INVESTIGATION FINDINGS:
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On February 25, 2025 at approximately 12:30 PM, Licensing Program Analyst (LPA), Kevin Mknelly, arrived unannounced at Walnut House for the purpose of delivering complaint findings. LPA met with Director, Allison Lopez to deliver an amendment to the report delivered February 11, 2025.

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. The evidence gathered was reviewed by the department.

Complaint alleges that Staff did not prevent a resident from developing pressure injuries while in care. Based on interviews that were conducted, resident files reviewed, and medical records reviewed, records review and interviews found that prior to the events of December 14, 2024, R1 was known to get up in the morning, dress, turn on lights, open blinds and turn on the tv, use their wheelchair to have coffee and smoke independently. On December 14, 2025, the AM med tech observed R1 to be sitting on their bed when medications were dispensed. No additional ...Report continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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 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: 02/25/2025
NARRATIVE
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observation was provided when R1 did not come out of their room for coffee or smoking. When R1 did not come to lunch, caregiver (S1) observed R1 to be using the toilet. S1 asked if R1 wanted lunch. R1 declined with head and hand gestures. R1’s family member arrived to visit R1 at approximately 2 PM. The family reported R1 was still in pajamas, blinds were closed, lights and TV were off. R1 was seated on a toilet and could not get up. Family called for assistance, 9-1-1 was called and R1 was transported to an area hospital.

Medical records showed that R1 had pressure injuries to left and right buttocks as well as redness and bruising in the shape of the toilet seat. Additionally, medical records from the emergency department noted:
Rhabdomyolysis, Patient confused, a&o x1. Patient has a purplish red ring around the outside of the buttocks area from being left on toilet for hours at assisted living. Also found a fluid filled blister on the R buttocks/posterior thigh. Initially, presented from assisted living facility after being found on the toilet for hours due to weakness. Mild nontraumatic and nonexertional rhabdomyolysis and AKI with CK 3469 in the absence of any trauma or exertional causes. Per collateral information obtained from (R1’s family), patient has had progressive decline in function over the last few months on top of already limited baseline mobility due to prior MCA stroke. Etiology of rhabdomyolysis is suspected due to atorvastatin medication.
The Mayo clinic describes the most common signs and symptoms of rhabdomyolysis include:
· Severe muscle aching throughout the entire body
· Muscle weakness

Report continued
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 02/25/2025
NARRATIVE
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Complaint also alleges that 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, the preponderance of evidence standard has been met. During a review of the Medical Records on January 22, 2025, LPA learned that the resident was on the toilet for hours.
Staff records and interviews found that R1’s baseline is to have minimal verbal interaction, independently wake, dress toilet and transfer. On December 14, 2024, R1 had a change in their baseline patterns and activities. Facility staff did not recognize the change in behavior of R1 until alerted to R1’s change in condition by visiting family at 2:00 PM on December 14, 2024. No evidence was found that staff initiated increased communication efforts to determine if R1 needed assistance to get up from the toilet. R1 is known to have aphasia, English as a second language and to not readily request nor accept assistance. The caregiver assigned to R1 on December 14, 2024 has been employed for approximately 3 months. Caregiver failed to recognize R1’s change of condition.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview was conducted, and a copy of this report was signed and given to the Licensee along with Appeal Rights.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
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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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/26/2025
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes ...and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as …, deterioration of mental ability or a physical health condition are observed, the licensee shall
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Administraor agreed to provide training to all staff regarding observation and communication of resident status. The POC is to provide a date that training will be completed by. Training to be comleted by 3/12/25.
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 ensure... changes are... brought to the attention of the resident's physician and... This requirement was not met based on records and statements which found R1’s changes to physical and social function were not responded to. This posed an immediate risk to R1.
Civil Penalty Applied.
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Proof of training completed will include procedures for observation and communication throughout all employees for obsrving residents and alerting to changing in condition or activity. Proof of training to be submitted when completed.
Deficiency Dismissed
Type A
02/26/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
(a)Residents shall .. rights: (4) To care, supervision, and services …by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Administraor agreed to provide training to all staff regarding awareness of changes and communication skills for communicating with residents with communication disabilities. The POC is to provide a date that training will be completed by. Training to be comleted by 3/12/25.
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This requirement was not met based on records and statements that found staff did not recognize and respond to R1’s change of condition and increased need for assistance. This posed an immediate risk to R1.
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Proof of training completed will include General observations of residents for what would possible indicate a change for that resident as well as types of communication strategies for non-verbal residents. Proof of training to be submitted when completed.
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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
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