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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 09/06/2022
Date Signed: 09/06/2022 02:10:53 PM


Document Has Been Signed on 09/06/2022 02:10 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
SACRAMENTO AC/SC, 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: 52DATE:
09/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Charles White TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Kesha Lewis and Albert Johnson arrived at this facility unannounced to conduct a case management visit for incident reports received on 09/01/2022 and 9/02/2022.

LPA's were met by Staff member and taken to Administrator. LPA's were screened upon entry for COVID precautions. LPA's explained the purpose of the visit to Administrator.

LPA's reviewed R1's facility file, physician's report reveals that resident has been determined to not be able leave facility unassisted without staff supervision. As a result of this incident, and review of pertinent documentation deficiencies.

LPA spoke to with Administrator about the facilities care plan/IPP for R1 going forward. LPA were unable to obtained copies of resident's functional assessment (pre-assessment) service plan and other pertinent information from R1's last placement because they were not in R1's file.

During the tour of the facility, LPA observed in the kitchen the fixed or Ansul system outdated, last service was on 9/29/2021. The system is scheduled to be checked semi- annually (Photo taken). This is a zero tolerance violation and a civil penalty will be assessed


As a result of this case management visit deficiencies were cited on the attached 809 D page, along with civil penalty assessed.

Exit interview conducted. Appeal rights discussed and a copy given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 09/06/2022 02:10 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2022
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 records reviewed R1 eloped from facility on 9/01/2022 and staff was not aware of R1 whereabouts. This poses an immediate health and safety risk to residents in care. An immediate civil penalty is assessed due to repeat violation.

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Creaste a needs and service plan for R1. Plan to be submitted to LPA by POC due date
Type A
09/07/2022
Section Cited

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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. This requirement was not met as evidenced by:

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LPAs observed that R1 diagnosed with dementia didn't have an assessment for addressing the AWOL’s after multiple AWOLs dating back to 8/2022

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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: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/06/2022 02:10 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2022
Section Cited

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met based on: Observation.
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 The facility failed to maintained in conformity with the regulations adopted by the State Fire Marshal. The "Fixed System" or "Ansul System" in the kitchen, this system is scheduled for a semi-annual maintenance and was last serviced on 9/29/2021
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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: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3