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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 02/27/2025
Date Signed: 02/27/2025 12:36:32 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
04/15/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240415090932
FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:VICKY CROSSFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 70DATE:
02/27/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Allison LopezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not ensuring that resident’s hygiene needs are being met.
INVESTIGATION FINDINGS:
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On February 27, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegation above. LPA met with Administrator and explained the purpose of the visit.

During the course of the investigation, LPA conducted extensive interviews, file review, and observations.

Please continue on LIC 9099-C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
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 5
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
04/15/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240415090932

FACILITY NAME:WALNUT HOUSEFACILITY NUMBER:
342700186
ADMINISTRATOR:VICKY CROSSFACILITY TYPE:
740
ADDRESS:3401 WALNUT AVETELEPHONE:
(916) 483-6612
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:110CENSUS: 70DATE:
02/27/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Allison LopezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly trained
Staff are not providing comfortable accommodations for resident
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
On February 27, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegation above. LPA met with Administrator and explained the purpose of the visit.

During the course of the investigation, LPA conducted extensive interviews and room observations.

Please continue on LIC 9099-C(1).

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
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 5
Control Number 59-AS-20240415090932
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: 02/27/2025
NARRATIVE
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LIC 9099-C(1)

Allegation: Staff are not properly trained.

The Department conducted extensive interviews regarding staff training on bed bugs. Based on interview conducted for S1 revealed S1 was informed to observe residents skin for redness and/or rash. Additionally S1 was informed to inspect the bottom of the beddings for bugs as bed bugs are nocturnal and likes to be hidden in darkness. S1 stated if confirmed bed bugs are observed in the room, S1 is gather clothing for the resident for a hot wash, then shower the resident and relocate the resident to a new room. S1 stated bed bugs reporting are to be reported to Administrator for pest control services. Interview conducted with S2 revealed S2 has been working as maintenance for a long time at multiple facilities. S2 stated S2 is aware how bed bugs looks like and if it was observed in residents room, S2 will assist with contacting pest control services and block off the room while caregivers are to assist with washing residents clothing with hot water, and providing residents with a shower before relocating the resident to a vacant pest free room. Interview conducted with S3 revealed that S3 often assist with housekeeping. S3 stated if there is suspicions of bed bugs, staff are to contact maintenance for inspection, once confirmed, resident will need to be showered while their clothing are being washed then resident and clean clothing are relocated to a new room until their original room is serviced. Interview conducted with S4 revealed that S4 is a caregiver and assist with bed making in the morning. S4 stated that when making the bed, they are to look under the bed mattress to ensure no bugs are detected. S4 stated if S4 observes bedbugs, S4 is to notify front desk or manager on the floor. S4 stated S4 will then assist with the resident relocation by making sure residents and their clothes are cleaned then will relocate to the new room. Interview conducted with S5 revealed S5 is aware of the facility bed bugs issue. S5 stated if staff complains of itchiness or rashes, then skin check will be conducted along with room inspection. S5 stated if confirmed bed bugs are present, the room will need to be closed off. Resident will need to be showered. Caregviers will bag residents clothing for a hot wash in laundry room then deliver cleaned clothes to the new room. Based on the information provided, LPA found the allegation to be unfounded.

Please continue on LIC 9099-C(2)
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240415090932
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: 02/27/2025
NARRATIVE
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LIC 9099-C(2)

Allegation: Staff are not providing comfortable accommodations for resident.

Based on information provided by the reporting party, R1 was relocated to a new room due to bed bugs. R1's temporary room was observed to have no television, no phone and no other source of entertainment. Interview conducted with Administrator on April 24, 2024, it revealed Administrator was informed of the concerns from R1's family members. Administrator stated based on Title 22, facility is not required to provide televisions in resident's room. Administrator stated R1's television was unable to be moved to the new room at the time to prevent cross contamination, if it was to be moved to the new room there would be a possibility of transferring bed bugs to the new temporary room. Administrator stated based on information provided by pest control company, bed bugs can be hidden between beds, outlets, lamps, television. Based on Title 22, it is required for bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. Based on the room inspection conducted for R1's temporary room and four additional other rooms, it was observed facility was compliance to 87307 Personal Accommodations and Services.

Based on information obtained, the allegations of Staff are not properly trained and Staff are not providing comfortable accommodations for resident are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of the report was provided to Administrator.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240415090932
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: 02/27/2025
NARRATIVE
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LIC9099-C.

Allegation: Staff are not ensuring that resident’s hygiene needs are being met.

The Department conducted interviews regarding the allegation of this complaint. Based on interview conducted with R1 revealed R1 is not sure if staff are changing R1 regularly. R1 stated R1 is not sure who is R1's caregiver for the day. File review revealed R1 has vascular dementia with mental condition of confused and disoriented. Interview conducted with S1 revealed S1 is R1's caregiver of the day of interview. S1 stated R1 has been changed in the morning. S1 stated R1 has been changed by S1. Based on LPA's observation during day of visit, R1 was observed to be clean. Based on interview conducted with Administrator, it revealed the incident regarding R1's hygiene needs are not met was due to staff showering R1 in the communal shower. Administrator stated staff had forgotten R1's clean clothing after the shower and could not leave R1 unattended in the shower room therefore, R1 was transferred back to R1's room in R1's same clothing. Administrator stated that was when R1's family member came to the facility and became upset that R1 was in the same clothing, denying R1 was showered.

A finding that the complaint allegation of: Staff are not ensuring that resident’s hygiene needs are being met is 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 provided to Administrator.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5