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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 03/21/2023
Date Signed: 03/21/2023 04:04:38 PM


Document Has Been Signed on 03/21/2023 04:04 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:CHARLES WHITEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: DATE:
03/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Punni, Manisha TIME COMPLETED:
04:15 PM
NARRATIVE
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On 03-21-23 at 1:30pm, Licensing Program Analysts (LPA) Kesha Lewis and Licensing Program manager Liza King arrived unannounced to conduct a quarterly visit. LPA and LPM met with Administrator and explained the purpose of the visit.
LPA and LPM reviewed: 1 of 1 residents file.

1. Maintenance logs

2. Medication log sheets

3. Updated AWOL procedures

4. Recent incident reports

The facility failed to send Incident reports to the department R1 had multiple

5. Random resident medical assessments

6. Training records

7. Facility observation to ensure compliance and safety

Based on LPA and LPM"S records review there are multiple medication errors for R1. There is also an outdated needs and services plan.

An exception request for a catheter will be sent by 03/22/2023 via email to the LPA kesha.lewis@dss.ca.gov

Also the facility failed to send Incident reports to the department.

Exit interview conducted and copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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 4


Document Has Been Signed on 03/21/2023 04:04 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: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2023
Section Cited

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Restricted Health Conditions
(a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services:
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the facility will provide an exception request by COB 3/22/23, and conduct shift training to insure all staff are trained by 03/31/23 procures for safe handling and recognizing s/s.
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This requirement was not met based on record reviewed. R1 was sent back from the hospital with a catheter and they facility does not have an exemption. This poses an Immediate health and safety risk to residents.
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Type A
03/31/2023
Section Cited

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87463(c) Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, Needs and Services Plan.
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Administrator shall obtain a Needs and Services Plan for R1 by the date indicated. Proof of correction to be sent to Kesha.Lewis@dss.ca.gov by the date indicated.
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Needs and Services Plan. The licensee shall complete a Needs and Services Plan for each client. This requirement has not been met as evidenced by: Records review by LPA for R1. This poses an Immediate health and safety rick 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: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 03/21/2023 04:04 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: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2023
Section Cited

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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Occurrences, such as epidemic outbreaks...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Licensee shall submit by fax a statement that all written incidents will be submitted timely by fax to the department.
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This requirement was not met based on record reviewed of R1 file that had mutaple SIRs that were not sent to the Department. LPM King contacted the san joaquin county police department for 911 call logs and recieved mutiple reports that had not been sent to the department.
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Type B
03/22/2023
Section Cited

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All facilities shall have a qualified and currently certified administrator...the Department may require that the administrator devote additional hours in the facility...when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
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Licensee will submit a plan of action to LPA outlining provisions for ensuring certified Administrator coverage at least 40 hours per week. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, licensee did not ensure presence of a certified administrator at least 40 hour per week as required by the department during a meeting held on 10-21-21. This poses a potential health and safety 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: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/21/2023 04:04 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: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2023
Section Cited

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Incidental Medical and Dental Care Services: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPAs review of all resident's medication administration logs where LPA observed errors in documenting medication
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The facility will conduct additional medication administration training for all staff who administer medications
annual traing will be completed by 3/31/23 and an additional 1 hour monthly med training being 3/23/23 for 12 months. there will be MAR audits monthly by management and simmited to the LPA by the 10th of each month for 3 months.
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Administration logs fro R1 have missing days with no documentation of medications administered on multiple days which poses an immediate health, safety and 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4