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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 10/05/2020
Date Signed: 10/05/2020 10:30:03 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
08/27/2020 and conducted by Evaluator Ruth Wallace
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200827145444
FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:COLLINS, KATRICEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 55DATE:
10/05/2020
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Telephone Call with Katrice Collins - COVID-19 Pre-CautionsTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist in arranging for medical care appropriate to the conditions and needs of resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ruth Wallace contacted Administrator Katrice Collins on this day to conclude a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. A physical visit was not conducted in that the Department is not conducting Residential Care for the Elderly visits at this time, due to the COVID-19 virus.
During the investigation, LPA Wallace conducted interviews with Complainant, seven staff, two Licensed Vocational Nurses (LVN's), Social Worker, and Administrator.
The first allegation is Staff did not assist in arranging for medical care appropriate to the conditions and needs of resident. The staff notes, medical documentation, Home Health Nurses, Administrator, and interviews show no evidence of resident's (R1's) medical care and needs not being provided for.
Based on interviews, LPA's observations, and records review, the Department (CCLD) has found the allegation of Staff did not assist in arranging for medical care appropriate to the conditions and needs of resident. Unsubstantiated.
A finding that the complaint allegation(s) is 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, Appeal Rights, 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 Wallace on today's date.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020
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 2
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
08/27/2020 and conducted by Evaluator Ruth Wallace
COMPLAINT CONTROL NUMBER: 27-AS-20200827145444

FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:COLLINS, KATRICEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 55DATE:
10/05/2020
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Telephone Call with Katrice Collins - COVID-19 Pre-CautionsTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide proper sleeping arrangement for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ruth Wallace contacted Administrator Katrice Collins on this day to conclude a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. A physical visit was not conducted in that the Department is not conducting Residential Care for the Elderly visits at this time, due to the COVID-19 virus.
During the investigation, LPA Wallace conducted interviews with Complainant, seven staff, two Licensed Vocational Nurses (LVN's), Social Worker, and Administrator.
The first allegation is Staff did not provide proper sleeping arrangement for resident. The staff notes, medical documentation, Home Health Nurses, Administrator, and interviews show no evidence of resident's (R1's) proper sleeping arrangements not being provided. In fact numerous times the resident refused to get into the bed according to staff notes.
Based on documentation regarding proper sleeping arrangement the allegation is deemed UNFOUNDED. This agency has investigated the allegation noted above and have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or was without a reasonable basis.
An exit interview was conducted with Administrator Katrice Collins via telephone and a copy of 9099, Appeal Rights, 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 Wallace on today's date.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020
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 2