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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 08/12/2022
Date Signed: 08/12/2022 01:14:06 PM


Document Has Been Signed on 08/12/2022 01:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:GURPREET RAIFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: DATE:
08/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Belinda Guzman TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived at the above facility unannounced to conduct a case management visit regarding an elopement episode on 8/7/2022 for resident (R1). LPA met with Administrator Belinda Guzman and explained the purpose of the visit.

LPA reviewed the Unusual Incident/Injury Report dated 8/8/2022 stating that R1 went AWOL on 8/7/2022. R1’s physician’s report dated 1/14/2020 stated that R1 cannot leave the facility unassisted. LPA also reviewed R1’s physicians report and noted that R1’s Physician’s report is outdated and medical assessment and a reappraisal done at least annually.


As a result of today's visit, deficiencies are cited under Title 22, Division 6. An immediate civil penalty in the amount of $500 is assessed due to repeat violation within a 12-month period. An exit interview was conducted with Administrator Belinda Guzman and a copy of this report was left with Administrator Belinda Guzman. Appeal Rights provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2022 01:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2022
Section Cited

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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 was not met as evidenced by:
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Based on record review and interview R1eloped from facility on 8/7/2022 and staff was not aware of R1 whereabouts. This poses an immediate health and safety risk to residents in care. An immediate civil penalty of $500 is assessed due to repeat violation.
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Type B
08/26/2022
Section Cited

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87705(c)(5) Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually.
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This requirement was not met based on record reviewed. R1 is diagnosed with dementia and does not have a updated Physician report. This poses a potential health and safety risk to residents.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2