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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 09/13/2022
Date Signed: 09/14/2022 10:22:23 AM

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
08/26/2022 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220826143712
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: 53DATE:
09/13/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Chalres WhiteTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Lack of supervision result in resident AWOL
Medications not being provided as ordered
INVESTIGATION FINDINGS:
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2
3
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5
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7
8
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10
11
12
13
On 9-13-22 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the complaint allegations noted above. LPA met Administrator Charles White and explained the purpose of the visit. During this investigation, LPA reviewed medication log sheets for August 2022 and an incident report from 8-7-22. LPA also interviewed Administrator and S1.

Allegation:#1 Lack of supervision resulted in resident AWOL (Absence without leave): Based on interview it was determined that this allegation was related to a specific AWOL event which occurred on 8-7-22 in which Resident1 (R1) eloped from facility. Based on record review, a previous citation from a case management conducted on 8-12-22 was already issued to licensee on 8-12-22 due to this AWOL event. It was determined at that time based on interviews and record reviews that facility was unaware of R1s general whereabouts on 8-7-22. As a result, the preponderance of evidence standard for this allegation is met, therefore, this allegation is SUBSTANTIATED. {This document is ammended from a previous report written on 9-13-22}.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220826143712
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: 09/13/2022
NARRATIVE
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Allegation#2: Medications not being provided as ordered: LPA reviewed medication log sheets for August 2022 and interviewed Administrator. Based on record review, a previous citation from complaint #27-AS-20220804155808 was issued to licensee on 9-13-22 due to a substantiated finding of medications not given as prescribed. It was determined at that time based on interviews and record reviews that multiple medications were not given to Resident2 (R2) as prescribed. As a result, the preponderance of evidence standard for this allegation is met, therefore, this allegation is SUBSTANTIATED.

An exit interview was conducted with Charles White and a copy of this report was left with Charles. .

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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
08/26/2022 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220826143712

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
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Chalres WhiteTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Failed to provide resident with their incontinent supplies
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9-13-22 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the complaint allegation noted above. LPA met Administrator Charles White and explained the purpose of the visit. During this investigation, LPA interviewed Administrator, R3, R4, R5, and R6 as well as Staff1 (S1), S2, S3, S4, S5, and S6. LPA also conducted facility observation. Based on observation, facility has designated location for incontinent supplies as well as personal protective equipment (PPE) located in hallways next to med room. It was also determined that facility maintains adequate amounts of supplies available to residents in care at this time. Based on interviews, it was determined that residents have been receiving incontinence and other supplies timely and adequately when required and requested.

As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTATIATED. An exit interview was conducted with Charles White and a copy of this report was left with Charles.

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 3