392700306-2-16-2022-27-AS-KHOS-C2AMFF-20210421093415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 04/06/2021
Date Signed: 02/16/2022 12:11:35 PM

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
12/08/2020 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201208145316

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: 68	DATE:	04/06/2021
		UNANNOUNCED	TIME BEGAN:	02:39 PM
MET WITH:	Katrice Collins		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility not administering residents' medications as prescribed.
Facility not assisting resident in arranging for necessary medical services.
Staff not according resident with dignity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Johnson arrived unannouced to deliver findings. LPA was greeted by Assistant Administrator and later joined by Administrator Katrice Collins

Allegation: Facility not administering residents' medications as prescribed.
Based on records reviewed and interviews with residents the facility did not administer medications incorrectly on several occasions. The department reviewed medication errors that were reported to the department which detail other resident's medications being given to the wrong resident and missed medications. LPA also observed during the medciation review in the medication room with Admininstrator, Med tech and Assistant Admininstrator medications not stored properly and medication left on the top of the med chart in a disposable cup unattended. The allegation is substantiated.

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

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-20201208145316

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: 04/06/2021

NARRATIVE

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Allegation: Facility not assisting resident in arranging for necessary medical services. Bases on records reviewed and interview with the Med-tech on 4/6/2021, the facility did not follow the discharge orders for R1. R1 was discharged from the ER on 2/2/2021 with instructions to follow-up with primary care physician in 3-5 days. The facility failed to follow these orders and R1 was sent back to the ER on 2/9/2021 for treatment of the same medical issues including vomiting, diarrhea and becoming unresponsive with prompted by the Med-tech Marilyn. The allegation is substantiated.

Allegation: Staff not according resident with dignity. R1 was receiving gabapentin three times a day which helped her significantly, along with PT and OT. R1 states that after moving into Wagner heights, she did not receive most of her medications for several days, including the gabapentin, and as a result, her neuropathy has returned and it has impacted her independence greatly. R1 states that after the several days, she started getting the gabapentin for about a week but even during that week it was not administered correctly or consistently, and she has been without it again. She was unable to confirm dates. Based on the review of the medication administration record(MAR) for November 2020, the facility missed doses on multiple days from 11/3/2020 to 11/17/2020. The MAR is not filled out correctly, it is missing information and nurses notes on the back are inconsistent.

Exit interview was conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099, LIC 9099-D, and appeal rights were received. Administrator is to print out each report, sign it, and fax a signed copy to LPA at 916-263-4744.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
12/08/2020 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201208145316

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: 68	DATE:	04/06/2021
		UNANNOUNCED	TIME BEGAN:	02:39 PM
MET WITH:	Katrice Collins		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff not assisting resident with incontinence needs.
Staff not assisting resident with ADLs.

INVESTIGATION FINDINGS:

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Allegation: Staff not assisting resident with incontinence needs. Based on interview with R1 the following was obtained; a caregiver (CG) changed her diaper and when R1 soiled her diaper again (diarrhea) CG told her that she was just going to keep her lying on her side and she can stay that way until she is done pooping. R1 states that CG is supposed to have someone assisting her in changing R1’s diaper and bedding but that CG is able to do it on her own. R1 states that the caregiver who is supposed to help CG2 claims that her back is hurt and is unable to help. R1 states she pushed her pendant for assistance at 7am on 12/8/2020 as she had soiled her diaper. R1 states that she was sitting in that soiled diaper because nobody came to assist her for one hour. Administrator confirm that the facility does keep ADL sheet for incontinence and other supports, these forms are marked as being completed for the months reviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

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 4

Control Number 27-AS-20201208145316

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: 04/06/2021

NARRATIVE

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Allegation: Staff not assisting resident with ADLs. Based on records reviewed and ADL charting the facility is documenting that ADLs are being completed for AM, PM and NOC shifts. The completed documents supports the facilities statements, however, R1 states that the facility helps her with some things but feels that the facility is over stating what they do with the documentation. The allegation is unsubstantiated.

A finding that the complaint allegation(s) is/are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted with Administrator Katrice Collins via telephone and a copy of 9099 and 811(Confidential Names) was provided to Katrice via email, an electronic email read receipt confirms receiving these documents. Administrator will sign 9099, and send back electronic email to LPA Johnson on today's date.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4