Walnut Village

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to complete the investigation and deliver findings on the complaint allegation listed above. LPA explained the purpose of the visit upon entry. The complaint investigation consisted of interviews and document review. Regarding the allegation: Resident sustained multiple falls while in care During the investigation, interviews were conducted with 3 individuals including facility staff and a family member of Resident 1 (R1). Documents were reviewed and revealed that R1 did sustain falls while in care. According to documents, falls occurred November 16, 2019, August 14, 2020, and January 26, 2021. After the fall in January 2021, R1 was sent to skilled nursing for physical therapy before returning to the facility. Additional document review reveal, R1 was put on hospice July 13, 2021, and eventually passed away at the facility with their family at bedside. Continued on LIC9099C UnsubstantiatedRead the full finding— CDSS inspection report, January 22, 2026 · control 22-AS-20210201111047

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. Findings are based upon this investigation which included resident file review, tour of the physical plant of the facility and interviews conducted. It is alleged facility staff is admitting residents to the memory care unit without prior consent from the residents and/or their authorized representatives. File review reveled that resident (R1) does not reside in the memory care unit. Admissions agreement reflects R1’s apartment number which is located in the assisted living side of the facility. However, R1 does attend respite care in the memory care unit of the Continued on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, April 28, 2025 · control 22-AS-20250310104618

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to deliver the findings into the above allegations. LPA met with Executive Director (ED) Debbie Infield and stated the purpose of the visit. During the course of the investigation, LPA obtained and reviewed copies of records pertinent to Resident 1 (R1) to Resident 4 (R4). Interviews were conducted with (3) residents, Health Services Director (HSD) Pamela Lowe, and ED Infield. The investigation revealed the following: It was alleged that the facility did not complete a reappraisal prior to admission to the Memory Care Unit (MCU). It was reported that the reappraisals were not completed for R1 and R2. Regarding R1, the reappraisal was completed on January 30, 2023 and signed and dated January 31, 2023 after R1 was admitted to the MCU on January 4, 2023. R2 was admitted to the MCU on March 6, 2023 and a reappraisal was conducted on February 6, 2023. Per Title 22 Regulation, 87457 Pre-Admission Appraisal, facility did nRead the full finding— CDSS inspection report, March 15, 2023 · control 22-AS-20230307094722

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to deliver the findings into the above allegation. LPA Cho met with Executive Director (ED) Debbie Infield and stated the purpose of the visit. During the course of the investigation, LPA obtained and reviewed pertinent records for Resident 1 (R1), conducted interviews with R1 and the ED, and toured the library. The investigation revealed the following: It was alleged that the facility staff did not treat the resident with respect. Per review of the facility’s Shift Report, on December 2, 2022, R1 was asked to self-isolate due to pending Coronavirus 2019 (COVID-19) test results. R1 was observed and approached by the ED in the library and was asked to return to the apartment out of precaution. Interviews conducted revealed that R1 did not like the ED’s tone while the ED indicated that she spoke to R1 in a low voice. Due to conflicting statements, LPA is unable to corroborate the allegation. UnsubstantiatedRead the full finding— CDSS inspection report, February 21, 2023 · control 22-AS-20221212135103