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Inspection visit

complaint

WALNUT GARDEN IIILicense 195850246
Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

This reports supersedes report issued on 04/03/2024. Continued from LIC 9099 On 04/03/2024, from 10:15 a.m. to 5:30 p.m., LPA Conway conducted an unannounced 10-day complaint visit. LPA Conway met with administrator Izhak Illouz and assistant administrator Arlene Ceballos and explained the reason for the visit. From 11:10 a.m. to 12:54 p.m., the LPA conducted a tour of the physical plant, reviewed facility files, obtained copies of pertinent documentation relevant to the investigation, and conducted interviews with facility staff, administrator, and residents. Investigator Spindola conducted interviews on 04/24/2024, at approximately 11:00 a.m., with R1’s resident representative; on 05/14/2024, at approximately 1:00 p.m., with facility assistant administrator; on 06/04/2024, at approximately 9:00 a.m., attempted interviews with staff, left message; on 07/03/2024, from approximately 2:45 p.m. to 4:00 p.m., with administrator, staff, resident and R1’s healthcare case consultant. In addition, the investigator reviewed Encino Hospital Medical Center medical records, radiology results from Professional Imaging Network, and facility file documents related to the investigation. According to the review of the Encino Hospital Medical Center medical records, R1 was brought in by ambulance on 03/27/2024 after a ground level fall at the facility that morning. The records noted R1 had a history of hypothyroidism, hypertension, rheumatoid arthritis, advanced dementia with psychotic feature, poor mobility, hypercoagulable state, significant dyslipidemia, and chronic low blood pressure. A deformity was noted, and an x-ray revealed left wrist fracture. R1’s resident representative chose not to proceed with surgery and preferred conservative management. Continued on LIC 9099-C This reports supersedes report issued on 04/03/2024. Continued from LIC 9099-C The Department’s investigation revealed that on 03/27/2024, at approximately 10:00 a.m., Resident #1 (R1) sustained a fall in R1’s bathroom. The facility staff attended to R1 and contacted the assistant administrator who then contacted R1’s healthcare case consultant who in turn notified R1’s resident representative, who requested R1 have x-rays taken of R1’s left wrist at the facility, instead of having R1 hospitalized, if it was not necessary. The x-ray results revealed that R1 sustained a fractured left wrist. On 03/27/2024, during the evening hours, R1’s resident representative then gave approval to the facility staff to send R1 to the hospital for medical care. R1’s resident representative did not have any concerns regarding the care R1 receives at the facility. Based on the above information, the Department did not find sufficient evidence of neglect/lack of care and supervision, therefore, the allegations “Neglect/Lack of Care and Supervision: Resident #1 (R1) sustained a fractured wrist, while under facility care” and “Neglect/Lack of Care and Supervision: Facility staff failed to provide timely medical care for Resident #1 (R1)” are deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.

Citations

5 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(1)(B)Type B

    87211(a)(1)(B) Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible... events specified in (A) through (D) below….. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an incident report when R1 fell and fractured wrist, which posed a potential health and safety risk to residents in care.

  • 87355(e)(1)Type A

    87355: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:This requierment is not met as evidence by: Based on records reviewed staff #1 has been working at the facility but does not have backround clearance and it is not associated to the facilit, which poses and immediate safety risk to residents in care

  • 87411(a)Type A

    Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. There is no staff coverage from 7:00pm to 7:00am, which poses an immediate health and safety risk to residents in care.

  • 87458(a)Type B

    87458(a) Medical Assessment(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional ... kept in the resident's record. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s medical assessment was missing physician signature and date, and the section for authorization for release of medical information was blank, which posed a potential health and safety risk to residents in care.

  • 87463(b)Type B

    87463(b) Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, ..., including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not update R1’s appraisal needs and services plan to document R1’s change of condition which included behavioral issues and aggression which required medication adjustment, which posed a potential health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the January 14, 2025 inspection of WALNUT GARDEN III?

This was a complaint inspection of WALNUT GARDEN III on January 14, 2025. The inspection found no deficiencies and no citations were issued.

Were any citations issued to WALNUT GARDEN III on January 14, 2025?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.