392700306-12-7-2021-27-AS-LKIG-C9SNKK-20211217093204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 12/03/2021
Date Signed: 12/07/2021 07:04:34 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
11/01/2021 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211101101635

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:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Katrice Collins, Facility		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility did not have sufficient overnight staff

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 allegation. This investigation consisted of site inspections to the facility to conduct interviews with the facility administrator, staff, residents and other witnesses. LPA reviewed and obtained copies of the resident's (R-1) file, a staffing schedule and other documentation.

This investigation concluded that on the overnight shift on August 16, 2021, the facility had insufficient staffing. On this shift, the care home had scheduled two staff for 54 residents. One staff called in sick and the facility was unable to fill the position. During the night, a resident fell out of bed and the staff was not able to lift him back up and the Fire Department was called for lift assist.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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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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
11/01/2021 and conducted by Evaluator Bruce Jacobs

COMPLAINT CONTROL NUMBER: 27-AS-20211101101635

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:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Katrice Collins, Facility Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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9

Resident's postural support is in disrepair

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 allegation. This investigation consisted of site inspections to the facility to conduct interviews with the facility administrator, staff, residents and other witnesses. LPA reviewed and obtained copies of the resident's (R-1) files and other documentation.

This investigation concluded after several LPA inspections, interviews and record reviews that there was inadequate evidence to conclude that a resident's postural support was in disrepair . LPA interviewed the Facility Administrator, Facility staff and other witnesses who provided conflicting information on the allegation. LPA was able to observe the former resident's bed and it was in working condition at that time. The resident no longer lives in the care home.

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.

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: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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 3

Control Number 27-AS-20211101101635

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: 12/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/03/2022 Section Cited CCR 87415(a)(2)	1 2 3 4 5 6 7	Night Supervision (2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. This requirement is not met by observation, interviews and records review	1 2 3 4 5 6 7	Plan of correction: The Facility provide in-service training for the staff on care procedures for call ins and back up assistance and will submit a corrective action plan detailing operational plans for back up scheduling to ensure all shifts are able to be filled in cases of call offfs.
	8 9 10 11 12 13 14	On the overnight shift on 8/16/21, one of two scheduled staff called in sick and the facility was unable to fill the shift. One resident fell and the staff had to call the fire department for lift assist. 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: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

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