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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 08/12/2022
Date Signed: 08/12/2022 01:14:06 PM

Document Has Been Signed on 08/12/2022 01:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:GURPREET RAIFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 80CENSUS: DATE:
08/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Belinda Guzman TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived at the above facility unannounced to conduct a case management visit regarding an elopement episode on 8/7/2022 for resident (R1). LPA met with Administrator Belinda Guzman and explained the purpose of the visit.

LPA reviewed the Unusual Incident/Injury Report dated 8/8/2022 stating that R1 went AWOL on 8/7/2022. R1’s physician’s report dated 1/14/2020 stated that R1 cannot leave the facility unassisted. LPA also reviewed R1’s physicians report and noted that R1’s Physician’s report is outdated and medical assessment and a reappraisal done at least annually.


As a result of today's visit, deficiencies are cited under Title 22, Division 6. An immediate civil penalty in the amount of $500 is assessed due to repeat violation within a 12-month period. An exit interview was conducted with Administrator Belinda Guzman and a copy of this report was left with Administrator Belinda Guzman. Appeal Rights provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2022 01:14 PM - It Cannot Be Edited


Created By: Jason Lund On 08/12/2022 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2022
Section Cited

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Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:(d) Being aware of the resident's general whereabouts…This requirement was not met as evidenced by:
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Based on record review and interview R1eloped from facility on 8/7/2022 and staff was not aware of R1 whereabouts. This poses an immediate health and safety risk to residents in care. An immediate civil penalty of $500 is assessed due to repeat violation.
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Type B
08/26/2022
Section Cited

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87705(c)(5) Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually.
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This requirement was not met based on record reviewed. R1 is diagnosed with dementia and does not have a updated Physician report. This poses a potential health and safety risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022


LIC809 (FAS) - (06/04)
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