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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 10/18/2021
Date Signed: 10/18/2021 11:12:40 AM



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
08/16/2021 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210816110524
FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:COLLINS, KATRICEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 54DATE:
10/18/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Katrice Collins, Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not prevent resident elopement.
Resident was physically assaulted by another resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Administrator Katrice Collins to deliver investigation findings on the above allegations. This investigation consisted of site inspections to the facility to conduct interviews with the facility administrator, staff and residents. LPA reviewed and obtained copies of the resident's (R-1,2,3) files.

This investigation concluded that a resident (R-1) left the facility unassisted and the resident had a Physician's Report (LIC 602) stating the resident was not allowed to leave on their own. The resident left the facility and the resident's physician report documents that the resident is not competent to leave on her own. The resident left the facility on multiple other occasions with the knowledge of the facility staff.

The investigation also concluded that resident (R-2) was assaulted and injured by his roommate (R-3) in their room. Information obtained indicates the assault was unprovoked and the injured resident (R-2) was treated for his injuries at the hospital. Resident (R-3) no longer resides at the care home. The resident was recently accepted into the facility directly from the hospital and the facility did not have a pre-placement appraisal for the resident as required. Continued.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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
Control Number 27-AS-20210816110524
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: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306
VISIT DATE: 10/18/2021
NARRATIVE
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As a result of this investigation, LPA finds the allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.
Exit interview conducted and report provided. Appeals rights printed.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/16/2021 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210816110524

FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:COLLINS, KATRICEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 54DATE:
10/18/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Katrice Collins, Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility did not safeguard resident's money.
Resident sustained injuries while in care due to a lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Administrator Katrice Collins to deliver investigation findings on the above allegations. This investigation consisted of site inspections to the facility to conduct interviews with the facility administrator, staff and residents. LPA reviewed and obtained copies of the resident's (R-1,2,3) files.

This investigation concluded that resident (R-1) was determined not to have a mental impairment and to be capable of managing her finances per her Physician's Report (LIC 602) and the facility was not involved the resident's finances. The resident was deceived into providing money to unknown individual's who contacted the resident via text and email messages. The facility was unaware of any of this financial actions.

The investigation also concluded that resident (R-2) was assaulted and injured by his roommate (R-3) in their room. Information obtained indicates the assault was unprovoked and the injured resident (R-2) was treated for his injuries at the hospital. Resident (R-3) no longer resides at the care home. The resident was recently accepted into the facility directly from the hospital and the facility did not have a documented history of assaults or aggressive behaviors. However, the resident's (R-1) complete history was not documented prior to admissions to the care home. Continued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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 5
Control Number 27-AS-20210816110524
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: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306
VISIT DATE: 10/18/2021
NARRATIVE
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Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED.

Exit interview conducted, report provided to the Facility Administrator.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210816110524
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: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited
CCR
87458(b)(4)
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Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician.(b) The medical assessment shall include, but not be limited to:4) Identification of physical limitations of the person to determine his/her capabilities. This requirement was not met as
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Plan of Correction: The Facility Administrator stated that the resident has no mental impairment and believes the Physician's report is not accurate in identifying the resident's ability to safely leave the facility without assistance. A new LIC 602 is in progress and will provided to Licensing when obtained. Facility will review all resident's files and
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evidenced by: The resident (R-1) has a Physician's Report (LIC 602) that indicates the resident is not capable of leaving the facility unassisted. The has had left the facility on numerous occasions without staff assistance and the facility was aware of the resident's activities
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develop and submit a plan to ensure that the Physician's Reports are followed.
Type B
11/15/2021
Section Cited
CCR
87457(a)(1)
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Pre-Admission Appraisal - General
(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee...
(1) Sufficient information about the facility and its services shall be provided to enable all persons involved in the placement to make an informed decision regarding admission.
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Plan of correction: The Facility Administrator stated that this resident (R-3) was only in the facility on respite and no longer lives at this facility. The Licensee will review this section of the regulations and will submit a statement of understanding and will ensure compliance with acceptance of new residents and required assessments.
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his requirement is not met by observation and records review. The facility accepted a resident (R-3) into the facility directly from the hospital. The facility did have a pre-placement appraisal in the resident's file prior to admission. The resident (R-3) assaulted and injured his roommate (R-2).
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5