392700306-11-3-2021-27-AS-LKIG-C8LL46-20211109072501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 11/02/2021
Date Signed: 11/03/2021 07:17:16 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
09/20/2021 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210920135055

FACILITY NAME:	WAGNER HEIGHTS RESIDENTIAL		FACILITY NUMBER:	392700306
ADMINISTRATOR:	COLLINS, KATRICE		FACILITY TYPE:	740
ADDRESS:	2435 WAGNER HEIGHTS RD		TELEPHONE:	(209) 477-5353
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	80	CENSUS: 54	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Marievec Andrade, Asst. Business Manager		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident was not properly assisted with medication management.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Assistance Bustiness Manager Marievec Andrade to deliver investigation findings on the above allegation. 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 files.

This investigation concluded that a resident (R-1) was not properly assisted with her medications. One of the resident's medications were not ordered, not filled and not available to be administered for a brief period of time. Also, the Medication Administration Record (MAR) had several days were it was not documented that this daily medication had been administered.

As a result of this investigation, LPA finds the allegation 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 deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview conducted and report provided. Appeals rights printed

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210920135055

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: 11/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/02/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care c) .... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met. (2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Plan of correction: The Facility Administrator will review the regulations of Incidental Medical and Dental Care and submit a statement of understanding and compliance. The facility will review medication administration procedures and ensure all staff are properly trained and management will provide oversight and regular medication audits.
	8 9 10 11 12 13 14	This requirement is not met by observation and records review. The resident had orders for 17 medications and it was documented that one medication, Ibuprofen, was not available and not administered to the resident. This poses a potential safety risk to client(s) in care.	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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

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
09/20/2021 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210920135055

FACILITY NAME:	WAGNER HEIGHTS RESIDENTIAL		FACILITY NUMBER:	392700306
ADMINISTRATOR:	COLLINS, KATRICE		FACILITY TYPE:	740
ADDRESS:	2435 WAGNER HEIGHTS RD		TELEPHONE:	(209) 477-5353
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	80	CENSUS: 54	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Marievec Andrade		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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9

Facility's air conditioner is in disrepair
Facility is malodorous
Meals are not provided to residents in a timely manner
Facility does not have good quality foods for residents
Facility does not provide agreed basis services listed on the to admission agreement
Staff does not attend to resident's call light in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Marievec Andrade 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 files.

This investigation concluded after several LPA inspections, interviews and record reviews that the facility's air conditioners were operable and the facility temperature was in the required range. The facility was not observed to be malodorous on numerous visits and per resident interviews. Meals and menus were determined to meet nutritional requirements and of sufficient quality. There was not sufficient information to prove facility staff did not attend to resident's calls in a timely manor or did not provided services listed on admission agreement(s).

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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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