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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 04/13/2022
Date Signed: 04/14/2022 07:05:59 AM

Substantiated


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
03/29/2022 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220329155847
FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:GURPREET RAIFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 54DATE:
04/13/2022
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Gurpreet Rai, Facility AdministratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility did not follow COVID-19 procedures.

Facility does not post licensing materials (Residents Rights/Ombudsman Poster) in view of residents..
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Administrator Gurpreet Rai to deliver investigation findings on the above allegations. This investigation consisted of site inspections to the facility to conduct interviews with the facility administrator other witnesses.

This investigation concluded that the facility did not follow COVID-19 procedures and follow the visitor screening procedures detailed in the facility's mitigation plan. The facility did not screen visitors to the facility on more than one occasion. In addition, the facility does not have the Resident's Rights or Ombudsman posters 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: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
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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Control Number 27-AS-20220329155847
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: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights: (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... This requirement was not met as evidenced by: On 03/23/22 and 03/31/22 licensee did not ensure the personal rights of persons in care to have safe and
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Plan of Correction: The facility updated their mitigation plan and will detail plans for ensure the mitigation plan is followed and all visitors and workers are screened for COVID-19 symptoms prior to entry.
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healthful accommodations and to ensure visitors are in good health. The facility did not have COVID-19 infection symptom screening of visitors and did not implement a sign-in policy for all visitors to ensure compliance with one central entry point for COVID-19 symptom screening and the facility's mitigation plan. This poses a potential health and satiety risk to residents in care.
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Type B
05/13/2022
Section Cited
CCR
87468(c)
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Personal Rights: (c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement was not met as evidenced that the facility did not post Residents Personal Rights or the Ombudsman contact poster at the
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Plan of Correction: The facility will post the Residents Rights and the Ombudsman signage prior to the POC due date and send CCL proof of POC completion
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facility. This poses a potential health and satiety risk to residents 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: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2