392700306-5-19-2022-27-AS-LKIG-CEYNCP-20220601102103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 05/18/2022
Date Signed: 05/19/2022 07:11:42 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
05/03/2022 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220503100420

FACILITY NAME:	WAGNER HEIGHTS RESIDENTIAL		FACILITY NUMBER:	392700306
ADMINISTRATOR:	GURPREET RAI		FACILITY TYPE:	740
ADDRESS:	2435 WAGNER HEIGHTS RD		TELEPHONE:	(209) 477-5353
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	80	CENSUS: 57	DATE:	05/18/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Gurpreet Rai, Facility Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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9

Lack of adequate staff on the morning shift on May 2, 2022.

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 allegation. This investigation consisted of site inspections to the facility to conduct interviews with the facility administrator, staff and other witnesses.

This investigation concluded that the facility did not have an adequate number of staff on the morning of May 2, 2022. On this day, three caregivers and a Med Tech were scheduled and two caregivers and the med tech called off sick. The Facility Administrator was not able to find replacements for the absent workers until around 11:30 that morning. As a results, the facility was unable to provide the basic service of a scheduled medication administration.

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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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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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
05/03/2022 and conducted by Evaluator Bruce Jacobs

COMPLAINT CONTROL NUMBER: 27-AS-20220503100420

FACILITY NAME:	WAGNER HEIGHTS RESIDENTIAL		FACILITY NUMBER:	392700306
ADMINISTRATOR:	GURPREET RAI		FACILITY TYPE:	740
ADDRESS:	2435 WAGNER HEIGHTS RD		TELEPHONE:	(209) 477-5353
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	80	CENSUS: 57	DATE:	05/18/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Gurpreet Rai, Facility Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's (R-1) medications were not administered per doctor's orders on May 2, 2022.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Facility 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 resident placement and medical files. Medications and orders for the resident and other residents were reviewed.

This investigation concluded that on the morning of May 2, 2022, the facility was short of staff and the morning medication pass was delayed. However, upon a review of the resident's (R-1) medications and doctor's orders, there was no schedule time ordered to deliver this resident's (R-1) medication. Although the facility failed to follow the best practices for medication administration, it was not determined that the resident's (R-1) medications were not administered per doctor's orders on May 2, 2022 or that a Licensing regulation had been violated.

The preponderance of evidence standard has not been met, therefore the above allegation is determined to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies are being cited. Exit interview held, copy of report given.

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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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-20220503100420

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: 05/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/20/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The facility did not meet this requirement as evidenced by: On the morning of May 2, 2022, two caregivers and a med tech called in sick, causing the facility to be short of staff on this morning.	1 2 3 4 5 6 7	Plan of Correction. The facility has developed a contract with two staffing agencies and will utilize their staffing when needed. The facility will develop a plan to ensure staffing shifts are covered when there are unscheduled absences and submit the plan to the Licensing office by the POC due date.
	8 9 10 11 12 13 14	The morning medication pass is normally schedule at 8:00 AM, but was not begun until after 11:00 AM. This poses a potential health and safety risks to clients 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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

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