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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 06/24/2022
Date Signed: 06/24/2022 03:10:37 PM

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
05/16/2022 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220516162447
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: 56DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gurpreet Rai, Facility AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident eloped from the facility without staff knowledge

Staff did not inform authorized representative of resident's
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, staff and other witnesses. Records were reviewed and copies of pertinent documents were obtained for the complaint file.

This investigation concluded that on the evening of May 15, 2022, a resident (R-1) left the facility without staff's knowledge. The resident has a diagnosis of dementia and was not authorized by his physician to leave the care home without assistance. Care home staff did not notice the resident was missing until the following day when they were notified by a local hospital. In addition, the facility did not notify the responsible party as required.

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: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
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
05/16/2022 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220516162447

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: 56DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gurpreet Rai, Facility AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Resident fell and sustained an injury at the facility
INVESTIGATION FINDINGS:
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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 files.

This investigation concluded that on the evening of May 15th, a resident (R-1) left wth facility without being observed by care home home staff. While the resident was out of the facility and away from care home supervison, the resident reportedly fell and was later taken to the hosptial for observation The resident had no recall of the incident and no injuries were observed on the resdient by the assigned LPA.

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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220516162447
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: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
87458(b)(4)
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Medical Assessments:(b) The medical assessment shall include, but not be limited to:....(4) Identification of physical limitations of the person to determine his/her capability to participate in the programs provided by the licensee, including any medically necessary diet limitations. This requirement was not met as evidenced by:
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Facility administrator and the resident's family had the resident reassessed by the PCP to help determine if medications will help with the resident;'s agitation and exit seeking behaviors. The resident's behavior has since improved. The facility administrator will provide in-service training to all care staff on resident's 602 and observations of the clients.
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LIC 602 indicates that R1 is unable to leave facility unassisted and on the evening of May 15th 2022, the resident left the facility without staff's knowledge and it was the next day's morning care staff who observed that the resident was not in the care home. This is an immediate safety risk to clients in care.
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Type B
07/25/2022
Section Cited
CCR
87211
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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major
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Facility administrator will review the regulations on reporting requirements and submit a statement to Licensing of understanding and compliance by the POC due date.
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accidents which threaten the welfare, safety or health of residents,... This requirement was not met as evidenced by" A resident left the facility without staff knowledge on May 15 and it was the hospital and not the facility who informed the responsible party that the resident was being evaluated at the hospital. this poses a potential health and safety risk to clients 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: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3