392700306-2-16-2022-27-AS-KHOS-CBVK7S-20220222063936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 02/16/2022
Date Signed: 02/16/2022 10:30:34 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
12/28/2021 and conducted by Evaluator Bruce Jacobs

COMPLAINT CONTROL NUMBER: 27-AS-20211228102036

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: 56	DATE:	02/16/2022
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Gurpreet Rai, Facility Administrator		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Resident's room has a water leak
Resident's room has mold
Resident did not complete personal property inventory sheet
Facility did not safeguard resident belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Administrator Gurpreet Rai to conclude and deliver investigation findings on the above allegations. 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 Resident's (R-1) room had a leak or mold. LPAs observed no leak or mold in the room. The Administrator and Maintenance Supervisor denied the room had water leakage or mold or that those issues had been corrected. Statements and information from all parties were not consistent and the allegation that the facility did not safeguard the resident's property could not be proven with a preponderance of evidence. LPA observed a personal property inventory (LIC 621) in the resident's file.

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: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

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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