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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 09/13/2022
Date Signed: 09/13/2022 04:33:43 PM

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
08/04/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220804155808
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:
10:40 AM
MET WITH:Charles WhiteTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff do not distribute resident's medications as prescribed
Staff did not report resident's change in condition to appropriate parties
Staff did not provide resident with bed linen
INVESTIGATION FINDINGS:
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On 9-13-22 at 10:40am, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to deliver complaint findings for the allegations listed above. LPA met with Administrator Charles White and explained the purpose of the visit. During this investigation, LPA conducted interviewed Staff1 (S1) S2, S3, S4, and S5. LPA also reviewed medication log sheets for Resident1 (R1), physician’s report for R1, medication orders for R1, medication release form for R1, facility staffing schedule for July 2022, 24-hour staff communication log dated 6-18-22 to 7-31-22, and blood sugar readings for R1 for the months of June, July, and August of 2022. LPA also conducted a facility observation on 9-13-22.

Allegation #1: Staff do not distribute resident’s medications as prescribed
LPA reviewed medication log sheets and physician’s orders as noted above. LPA also interviewed S1 and S2. Based on interviews and record reviews, it was determined that multiple medications and multiple blood sugar checks during the period of June, July, and August of 2022 on the medication log sheets for R1 contained no staff signature to indicate R1 received medications and blood sugar checks. {Cont. on LIC 9099C}
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 4
Control Number 27-AS-20220804155808
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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Furthermore, based on interviews, it was revealed that no additional evidence exists to indicate R1 received the medications and blood sugar checks. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation #2: Staff did not report resident’s change in condition to appropriate parties
LPA reviewed medication orders for R1, 24-hour staff communication log, and blood sugar readings for R1 as stated above. LPA also interviewed S1. Based on record reviews and interviews, it was determined that R1’s physician was to be notified if blood sugar reading above 400. During record review, it was further determined that blood sugar for R1 read at over 400 on multiple dates during June and July of 2022. A review of 24-hour communication log and R1s general record revealed no entries were made to indicate physician was notified of the blood sugar reading. An interview with S1 determined no confirmation of physician notified. Based on interviews and record reviews, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation #3: Staff did not provide resident with bed linen

LPA conducted a facility observation and interviewed S1, S2, S3, S4, and S5 and R1, R2, R3, and R4. Based on interviews and observation conducted on 9-13-22, it was determined that a history exists within facility which includes a shortage of bed linen available for residents in care, as well as witness of residents in bed without appropriate linen. Linen closet was observed to contain minimal amounts of linen and 2 of 4 rooms contained beds with little to no linen at time of observation. Based on observation and interview, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.


Citations are issued as indicated on LIC 9099D. 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220804155808
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: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2022
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.…This requirement was not met as evidenced by:
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Licensee will conduct medication training on use of medication log sheets (MARS) as well as importance of receiving medications as ordered, and submit scheduled training date to LPA by POC due date. Proof of training to be sent to LPA no later than 2 weeks from the date of this citation issuance.
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Based on record review and interview, R1 did not receive multiple prescribed medication on multiple dates as indicated on medication log sheets dated June, July, and August of 2022. This posed an immediate health and safety risk to resident in care.
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Type A
09/14/2022
Section Cited
CCR
87465(a)(1)
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 Incidental Medical and Dental care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care...(1) The licensee shall arrange, or assist in arranging, for medical...care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee will conduct medication training on following physician’s orders and submit scheduled training date to LPA by POC due date. Proof of training to be sent to LPA no later than 2 weeks from the date of this citation issuance.

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Based on interview and record review, R1’s blood sugar readings were not reported to R1’s physician per physician’s orders instructions. This posed an immediate health and safety risk to resident in care.
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Licensee will develop and submit a plan ensuring residents’ physician’s orders will be followed per instruction. Plan to be submitted to LPA by POC due date.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220804155808
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: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by
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Licensee will inventory linen supply and send completed inventory count indicating adequate amounts based on resident needs to LPA by POC due date.

Licensee will develop plan to ensure appropriate amounts of linen are available to residents in care. Plan to be submitted to LPA by POC due date.
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Based on observation and interviews, licensee did not ensure appropriate amounts of bed linen for residents in care. This poses a potential health, safety, and resident 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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4