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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 09/13/2022
Date Signed: 09/13/2022 05:01:42 PM


Document Has Been Signed on 09/13/2022 05:01 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:
09/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Charles WhiteTIME COMPLETED:
03:00 PM
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
On 9-13-22 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to conduct a case management visit regarding medication documentation. LPA met with Administrator Charles White and explained the purpose of the visit. LPA reviewed medication log sheets for resident1 (R1) and conducted interview with Staff1 (S1) and S2. Based on record review, it was determined that two sets of medication log sheets obtained on the dates 7-13-22 and 7-22-22 revealed an insulin medication to be given based on blood sugar readings. Insulin, which is to be given to R1 based on blood sugar readings indicates on the 7-13-22 copy that it was given on July 5, 6, 7, 8, 10, 11, and 12 of 2022. The copy received on 7-21-22 indicated the insulin was given consistently from July 1 to July 21, 2022. The initials to indicate insulin as given from July 1, 2022, were not present on the 7-13-22 copy.

Additionally, during record review it was indicated on R1’s medication log sheet that medication Levetiracetam was transcribed as 800mg 2 tabs twice daily. The medication order for this medication was written as 500mg 2 tabs twice daily. An interview with S1 revealed no explanation for medication log sheet discrepancies noted above.

As a result of today’s case management visit, citations are issued under Title 22, Division 6, Chapter 8. An exit interview was conducted with Charles White and a copy of this report was left with Charles. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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 2


Document Has Been Signed on 09/13/2022 05:01 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: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2022
Section Cited

1
2
3
4
5
6
7
Personnel Requirements. (a) Facility personnel shall at all times be…competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on record reviews and interview, Licensee did not ensure staff competence in that discrepancies existed on medication log sheets for R1. This posed and immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Licensee to conduct staff medication training to cover the importance of medication log accuracy and proper procedures for medication documentation. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance.

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: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2