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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 04/16/2025
Date Signed: 04/16/2025 01:47:25 PM

Unfounded


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
04/29/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240429170257
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: 66DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Allison LopezTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Due to neglect, resident sustained fractures.
INVESTIGATION FINDINGS:
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On April 16, 2025, Licenisng Program Analyst (LPA) Cassie Yang arrived at the facility to deliver the findings of the allegation cited above. LPA met with Administrator and explained the purpose of the viist.

During the course of this investigation, LPA has conducted extensive file reviews to conclude the finding of the allegation.

Please continue on LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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 3
Control Number 59-AS-20240429170257
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: 04/16/2025
NARRATIVE
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LIC 9099-C

Allegation: Due to neglect, resident sustained fractures.

Based on file review of LIC 624 UNUSUAL INCIDENT/INJURY REPORT, it revealed on April 8, 2024 at approximately 7:20 pm R1 was observed on the floor during rounds, appeared to have a fall. Staff contacted paramedics immediately, along with family and primary care physician. R1 was transported to the emergency room for evaluation. Based on file review of Sutter Roseville Medical records, it reveal primary impression was traumatic injury. R1 disclosed to paramedics that R1 was "getting out of bed to go smoke and I rolled off my bed onto the floor." Records revealed that Public Safety Answering Point (PSAP) was notified of fall on April 8, 2024 at 19:25:26 (7:25:26pm) where emergency medical services was notified for dispatch at 19:25:34 (7:25:34pm) which emergency medical services was en route at 19:28:37 (7:28:37pm) and arrived to the facility at 19:44:37 (7:44:37pm) assisting R1 at 19:47:00 (7:47pm).

File review of staff schedule revealed during time of fall, there was two shift managers on the floor, along with four care staff. Review of R1's Alarms By Apartment By Location from April 1, 2024 to April 30, 2024 revealed there was no call for assistance.

File review of R1's incident reports did not reveal any history of falls. File review of R1's LIC 602A PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) revealed R1 has primary diagnosis of Severe protein calorie malnutrition with secondary diagnosis of "COPD". File review of Sutter Health Medical records further revealed R1 is "on Eliquis for history DVT and rheumatoid aortitis with additional pertinent history of dementia and osteoporosis". Medical records further revealed R1 sustained bilateral femur fracture who then found to be tachycardic with elevated troponin which resulted to R1 being placed on comfort care measures until R1 passed away.

Based on the information obtained through file reviews, it revealed R1 did sustained fracture due to an unwitnessed fall, but facility did seek medical attention immediately. Facility did not indicate any neglect as staff completed post-dinner routine checks on residents in care which led to finding R1 on the floor.

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

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240429170257
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: 04/16/2025
NARRATIVE
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LIC 9099-C (2)

Based on information obtained, the allegation Due to neglect, resident sustained fractures, is determined 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: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3