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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 03/04/2022
Date Signed: 03/07/2022 07:03:05 AM

Document Has Been Signed on 03/07/2022 07:03 AM - 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: 46DATE:
03/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Gurpreet Rai, Facility AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Bruce Jacobs conducted a case management visit at the facility to issue a deficiency relating to an incident report not submitted to the Department. LPA met with Facility Administrator Gurpreet Rai and the purpose of the visit was disclosed. Licensing received information from the Local Health Department that a residents had tested recently positive. The resident was tested on 2/23/322 and had a positive test result on 2/28/22. This case was not reported to Licensing by the facility as required.

A case management deficiency for failure to report as required is being issued on the following 809D. Appeal rights provided and exit interview conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/07/2022 07:03 AM - It Cannot Be Edited


Created By: Bruce Jacobs On 03/04/2022 at 11:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2022
Section Cited
CCR
87211(a)(1)(B)

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision 87211(a)(2) Occurrences such as epidemic outbreaks.
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Plan of Correction: The Facility Administrator will review the corresponding regulation on reporting requirements. Facility will submit a statement to the Department by the POC due date that this regulation has been reviewed, understood and is being followed
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This requirement was not met as evidenced by: A resident at the facility tested positive for an infectious disease on 2/28/22. The facility did not report these cases to Licensing and therefore failed to submit an incident as required to the department. This poses a potential Health and Safety risk to clients 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 King
LICENSING EVALUATOR NAME:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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