<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700074
Report Date: 05/08/2023
Date Signed: 05/08/2023 12:09:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230323154901
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 2FACILITY NUMBER:
392700074
ADMINISTRATOR:WALTERS, MOSES SRFACILITY TYPE:
735
ADDRESS:4717 WHITE FORGE DRIVETELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 4DATE:
05/08/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:M. WaltersTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mismanaging resident's medication log.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Albert Johnson arrived unannounced to deliver findings.

Based on records reviewed the facility failed to document the administration of medications for residents in care. The facility alleged that the medication for the residents was given, however the log for 3/21/23 for all day and 3/22/23 had no initials for the AM meds, some residents had missing initials for 3/20/23.

As a result, the preponderance of evidence standard for this allegation is met, therefore, this allegation is SUBSTANTIATED. deficiencies cited on the attached 9099D page.

Exit interview conducted.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
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 4
Control Number 27-AS-20230323154901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 2
FACILITY NUMBER: 392700074
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
80075(b)(6)(C)
1
2
3
4
5
6
7
80075(b)(6)(C) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met:
1
2
3
4
5
6
7
THE LICENSEE SUBMITTED CORRECTIONS TO LPA WHICH INCLUDED STAFF TRAINING. LPA OBSERVED SUBMITTED CORRECTIONS AND ACCEPT THEM TO FULFILL CCL POC.

POC CLEARED
8
9
10
11
12
13
14
This requirement has not been met as evidenced by: Based on observation the licensee failed to ensure resident's medications were documented as required.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2023 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20230323154901

FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 2FACILITY NUMBER:
392700074
ADMINISTRATOR:WALTERS, MOSES SRFACILITY TYPE:
735
ADDRESS:4717 WHITE FORGE DRIVETELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 4DATE:
05/08/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:M. WaltersTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not have an adequate food supply.
Staff do not provide a food menu to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Allegation: Staff do not have an adequate food supply. Based on observation and records review the facility has the required food supply in the facility.

The facility has two refrigerators available for the storage of food for the required two day perishable and the seven day non-perishable requirement.

LPA was told that the staff will bring items into the facility from the garage to restock the refrigerator inside the facility. Staff mentioned that there are times when the food from the garage refrigerator is not brought in to restock and that may have been the reason for the inside refrigerator not being stocked on the day of the visit. LPA was able to review receipts for groceries bought prior to the complaint allegation.
Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230323154901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WALTERS RESIDENTIAL HOME CARE 2
FACILITY NUMBER: 392700074
VISIT DATE: 05/08/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff do not provide a food menu to residents. Based on observation and interviews conducted the facility has posted a menu that reflects what will be potentially served for the residents. The facility has posted on the board in the living room area a menu.
The facility staff confirmed that the residents do not ask for a menu of what will be served. The staff stated that the residents that are able will go to the board and look for what is being served. Staff stated that residents will just ask the question of staff or just go to the kitchen and look at what is being cooked. (Until they are asked to leave the kitchen for safety reasons.)

LPA was unable to confirm or deny that the facility does not give the residents a menu.(It is posted however in a common area.)

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4