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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 11/03/2020
Date Signed: 11/03/2020 04:35:06 PM



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
05/13/2020 and conducted by Evaluator Anthony Tuck
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200513140144
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: 61DATE:
11/03/2020
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Katrice CollinsTIME COMPLETED:
04:48 PM
ALLEGATION(S):
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The Telephone in the facility is not in good operating condition as calls get dropped and phone rings then goes to busy signal.
INVESTIGATION FINDINGS:
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LPA called the facility on 11/03/2020 at approximately 04:00pm. LPA spoke with Administrator Katrice Collins to deliver findings and close complaint investigation.

LPA conducted investigation by contacting the facility on 05/18/2020, 05/21/2020 and to residents responsible parties on 06/15/2020 to determine the functionality of the facility phone line system. An additional call was made by another CCLD staff member on 05/29/2020 to attempt to reach the facility. The phone rang and went to busy signal and did not transfer to voice mail system. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099, LIC 9099-D, and appeal rights were received. Administrator is to print out each report, sign it, and fax a signed copy to LPA at 916-263-4700. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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
Control Number 27-AS-20200513140144
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: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2020
Section Cited
CCR
87468.1(a)(9)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights (9) To have communications to the licensee from their representatives answered promptly and appropriately.
This requirement was not met as evidenced by:
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Licensee stated the phones have already been repaired and answering system now operates correctly to pick up on answering system when all lines are busy. Licensee will email LPA copy of service invoice for proof of correction.
Proof of correction due by 11/04/2020
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Based on interviews and calls made to the facility. The facility phone line at times were not answered. The phone system did not have the ability to switch over to the voice answering system if both lines were in use. This poses a potential personal rights risk to residents 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
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