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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700186
Report Date: 05/13/2025
Date Signed: 05/13/2025 04:47:22 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
06/21/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240621115513
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:
05/13/2025
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Allison LopezTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Facility staff mismanaged residents medication

INVESTIGATION FINDINGS:
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On May 13, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to investigate and deliver the finding of the allegation cited above. LPA met with Administrator and explained the purpose of the visit.

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

The result of the investigation is as follow, please continue on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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
06/21/2024 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20240621115513

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:
05/13/2025
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Allison LopezTIME COMPLETED:
04:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not providing residents with assistance in cleaning their rooms
Facility staff do not respond to residents call buttons in timely manner
Facility staff are not properly assisting residents with showering
Facility staff are not providing adequate laundry services for resident
INVESTIGATION FINDINGS:
1
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3
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5
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7
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9
10
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12
13
On May 13, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to investigate and deliver the findings of the allegations cited above. LPA met with Administrator and explained the purpose of the visit.

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

The result of the investigation is as follow, 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: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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-20240621115513
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: 05/13/2025
NARRATIVE
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LIC 9099-C (1)

Allegation: Facility staff are not providing residents with assistance in cleaning their rooms.

File review of housekeeping schedule for June 2024 revealed facility has two housekeepers who work at the facility five (5) days a week. Based on interview conducted with Administrator, it revealed that R1 is an artist and likes to have art supplies in R1’s room. R1 likes to “hoard” and creates mini clutter, such as keeping scraps of paper around the room. R1 has been upset on multiple occasions when staff are cleaning R1’s room when R1 is out of the community. Interview further revealed that R1 is willing to have housekeepers vacuum the floor and clean the bathroom, but does not like staff removing papers. R1 has had external assistance for hoarding anxiety. Based on LPA’s observation of R1’s room, it revealed there is a clear pathway from the door to the bed to the bathroom. LPA did not observe any obstructions in the pathway. Interview conducted with R1 revealed that R1 likes the room the way it is. R1 does not mind staff coming in for housekeeping days to vacuum and clean, but does not like her art supplies and/or papers to be missing. R1 likes to throw crumbled papers on the floor but may “need it later” and prefers the papers not to be discarded. Therefore, the allegation is unfounded.

Allegation: Facility staff do not respond to residents call buttons in timely manner.

The Department conducted file reviews and interviews regarding the allegation cited above. Based on file review of six residents’ call log for June 14-20, 2024, it revealed the average response time for R2 was five (5) minutes and 23 seconds, R3 was three (3) minutes and 42 seconds, R4 was 3 minutes and 50 seconds, R5 was nine (9) minutes and 13 seconds, R6 was 12 minutes and 3 seconds, R7 was 10 minutes and 24 seconds, and R8 was 5 minutes and 19 seconds. Interview conducted with Administrator revealed that there were no unusual incident reports filed; therefore, the call button may have been pressed for minor assistance. File review of incident reports and/or charting notes revealed that there were no medical emergencies for R2, R3, R4, R5, R6, R7, and R8 during this duration. The allegation is unfounded.

Please continue on LIC 9099-C (2).

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240621115513
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: 05/13/2025
NARRATIVE
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LIC 9099-C (2)

Allegation: Facility staff are not properly assisting residents with showering.
Interview conducted with Administrator revealed that residents are showered twice a week, with approximately 80% of residents needing assistance with showering. Interview further revealed that if residents in care refuse showers, caregivers are to be notifying supervisors immediately so supervisors can intervene and negotiate with the resident on showering. Interview conducted with R10, R11, R12, R13, R14 and R15 revealed that there are no concerns and/or issues regarding showering at the facility. Interview further revealed they do not have issues with receiving shower services. Interview conducted with S3 revealed S3 is a caregiver at the facility. S3 stated that if a resident declines a shower on their shower day, then it is to be documented and will attempt to rescheduled for the following day if working. Interview conducted with S4 and S5 revealed that they provide approximately three (3) to five (5) showers per shift depending on the hall and if the residents are frequent refusers. Interview further revealed that if residents refuse showers, caregivers are to "change face" and have another caregiver offer the showering, if declined, then supervisor will intervene. If unsuccessful then the shower refusal form will get signed by supervisor on the floor. The allegation is unfounded.

Allegation: Facility staff are not providing adequate laundry services for resident.

The Department conducted extensive interviews regarding laundry services. Interview conducted with Administrator revealed facility provides residents in care with washing and drying. There is a full-time laundry staff at the facility from Sunday to Thursday, with an assigned hall per day. Laundry is to be washed and returned to residents within the same day. Interviews conducted with R9, R10, R11, and R12 revealed that they do not have any concerns regarding basic laundry services at the facility. Interview conducted with R13 revealed R13 has been a resident at the facility for over two (2) years. R13 indicated that laundry services have gotten better. During the day of the interview, it was R13’s laundry day, which was gathered for washing at approximately 7:00 a.m. and returned to room at approximately 1:30 p.m. The following allegation is unfounded.

Based on information obtained through file review, interviews, and observations, the allegations listed above 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.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240621115513
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: 05/13/2025
NARRATIVE
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LIC 9099-C

Allegation: Facility staff mismanaged residents medication.

The Department conducted several interviews regarding staff mishandling medications. Interview conducted with R12 revealed that R12 does not have any issues regarding medications not being passed. Interview revealed R12 does not have dementia and is able to identify their own medication. There have been a few occasions when R12 had to remind the medication technician (med tech) on the floor that a medication was missing from administration. Interview conducted with R15 revealed R15 did not receive their medication for the day. Additionally, R15 was unable to identify the day’s date. File review of R15’s LIC 602 Physician’s Report revealed R15 has dementia. Interviews conducted with S1 and S2 revealed they both ensure it is the right medication, right time, right dose to the right person. Interview revealed that with the new electronic medication administration records system, medication administration has been easier, where S1 does not confirm medication has been taken in the system until confirmed passing. Interview further revealed that in the past, it was not clear if it was mandatory to visually confirm medications have been passed, but with the implementation of Administrator’s policy and procedures, all med techs are now required to stand and confirm medication has been taken before moving to the next resident in care. Information provided by Reporting Party included a photo of a napkin with pills on top of a dresser and a pill on the floor; however, LPA was unable to confirm the time, date and place of photo taken. On date of deliver finding, LPA observed med techs conduction medication pass and observed med techs to be watching residents to confirm medications has been taken. The following allegation is unsubstantiated.

A finding that the complaint allegation of: Facility staff mismanaged residents medication 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5