<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 07/15/2022
Date Signed: 07/15/2022 03:22:17 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
07/01/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220701123426
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: 58DATE:
07/15/2022
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Gurpreet RaiTIME COMPLETED:
01:38 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident eloped from the facility
Staff do not have required training
Facility is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7-15-22 at 9:58am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue complaint investigation for the allegations noted above. LPA met with Administrator Gurpreet Rai and explained the purpose of the visit. During this investigation, LPA interviewed Administrator, Staff1 (S1), Resident1 (R1), and R3. LPA also reviewed physician’s reports for R1, R2, R3, and R4, Staffing record for S1, Resident sign in and sign out sheet for June-July 2022, incident report for R3, staffing schedule for June and July of 2022, and actual hours worked for June and July 2022. LPA also conducted a facility observation on 7-7-22.
Allegation #1: Resident eloped from the facility. LPA interviewed Administrator and S1 on 7-7-22. LPA also reviewed incident report stating R3 was noticed to be missing after breakfast on 7-2-22 at 9:10am, in addition to facility “elopement and resident missing policy” Incident report stated staff was unable to locate R3 and facility was later notified by law enforcement that R3 was at the hospital. An observation by LPA on 7-15-22 revealed R3 eloped from facility and facility staff was later notified of R3's location by law enforecement. Based on interviews and record reviews, it is determined that R3 exited facility without staff’s knowledge of her general whereabouts. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
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 5
Control Number 27-AS-20220701123426
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
VISIT DATE: 07/15/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation #2: Staff do not have required training. LPA reviewed staffing record for S1, and interviewed S1 and Administrator. Based on record review and interview it was determined that S1 possess a certified medication training from another licensed facility, but did not receive regulatory required medication training specifically at Wagner Heights Residential after employment began on 7-7-15. It was further confirmed through interviews that S1 assisted residents with medication. Based on interviews and record reviews, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation #3: Facility is in disrepair. LPA conducted a facility observation on 7-7-22 with Administrator present. During facility observation, LPA observed drywall to be chipped and peeling on multiple pillars in the kitchen including near food prep area. Interviews conducted revealed that appropriate personnel where unaware of the chipped and peeling drywall. Based on observation and interviews, it is determined that the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Due to repeat violation within 12-month period, a civil penalty in the amount of $250 is assessed.

Based on the findings above, citations are issued under Title 22, Division 6 and Health and Safety Codes. An exit interview was conducted with Gurpreet Rai and a copy of this report was left with Gurpreet. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/01/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220701123426

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: 58DATE:
07/15/2022
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Gurpreet RaiTIME COMPLETED:
01:38 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have written menus kept on file
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7-15-22 at 9:58am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue complaint investigation for the allegation noted above. LPA met with Administrator Gurpreet Rai and explained the purpose of the visit. During this investigation, LPA interviewed Administrator and reviewed facility’s menu for June and July. Based on interview and record review, it was determined that facility has a menu on file and is currently posted. As a result, the preponderance of evidence standard is not met, and this allegation is UNFOUNDED.

An exit interview was conducted with Gurpreet Rai and a copy of this report was left with Gurpreet.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20220701123426
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: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2022
Section Cited
HSC
1569.312(d)
1
2
3
4
5
6
7
Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:(d) Being aware of the resident's general whereabouts…This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will conduct staff training on elopement procedures. Scheduled training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 7-22-22.
Licensee will submit a plan to ensure staff are aware of residents’ whereabouts. Plan to be submitted to LPA by POC due date.
8
9
10
11
12
13
14
Based on record review and interview, S3 eloped from facility on the morning of 7-2-22 and 7-15-22, and staff was not aware of S3’s whereabouts until informed by law enforcement of S3’s location. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
07/29/2022
Section Cited
HSC
1569.69(a)(8)(B)
1
2
3
4
5
6
7
Employees assisting residents with self-administration of medication; training requirements (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the...training requirements: (8) The training requirements of this section shall be repeated if either of the following occur: (B) An employee goes to work for another licensee in a facility in which he or she assists residents with the self-administration of medication.
1
2
3
4
5
6
7
Licensee will ensure S1 received necessary regulatory medication training and provide proof of completed training to LPA by POC due date. Licensee to ensure S1 does not assist residents with medication until training is complete.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on interviews and record review, S1 assisted residents with self administration of medication at Wagner Heights Residential, received previous medication training at another licensed facility, but did not repeat training at Wagner Heights Residential per regulatory requirements. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Licensee will conduct audit of staffing charts to ensure all regulatory training is complete, accurate, and current. Audit to be submitted to LPA by POC due date.
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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220701123426
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: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2022
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will repair or replace peeling and cracked drywall, and submit photo proof of completion to LPA by POC due date.
8
9
10
11
12
13
14
Based on observation, cracked and peeling drywall was observed by LPA on 7-7-22 on multiple pillars in kitchen area including near food prep area. This poses a potential health and safety risk to residents in care. Due to repeat violation within 12-month period, a civil penalty in the amount of $250 is accessed.
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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5