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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 11/18/2021
Date Signed: 11/18/2021 10:37:11 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
10/12/2021 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211012163213
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:
11/18/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Gurpreet Rai, Assistant AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility has a pest infestation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Assistant Administrator Gurpreet Rai 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 (R-1,2,3) files and other documentation.

Based on interviews with residents, reviews of records and medical information and incident reports, this investigation concluded that several residents had contracted scabies and/or bed bugs at the facility.

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.
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: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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 2
Control Number 27-AS-20211012163213
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: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Plan of correction: The Facility has assisted the resident with scabies to get medical care and follow-up. The facility will assess the condition of the other resident. There have been several pest inspections and treatments at the care home and facility will continue to treat the facility and ensure care of the residents are provided.
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This requirement is not met bas determined by observation, interviews and records review. One resident was treated for scabies and another resident had several bug bites on his arms. A pest inspection report of 10/29/21 reports treatment based on sightings of bedbugs.This poses a potential safety risk to client(s) in care.
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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: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2