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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:18:32 PM

Document Has Been Signed on 08/03/2022 04:18 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: 54DATE:
08/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Gurpreet RaiTIME COMPLETED:
04:35 PM
NARRATIVE
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On 8-3-22 at 2:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding previous elopement episodes for resident1 (R1), R2, R3, and R4. LPA met with Administrator Gurpreet Rai and explained the purpose of the visit. LPA reviewed "detailed history for police events" which described police presence at facility due to R1, R2, R3, and R4 eloping. Dates of events ranged from 5-7-22 to 7-15-22 and described R1-R4 as "missing at risk."

LPA also conducted interview with Administrator and reviewed incident reports dated in range from 6/4/22 to 7/10/22. Based on interview and record review it was determined that R1, R2, R3, and R4 collectively engaged in elopement episodes between 5-7-22 to 7-15-22. Additionally, it was determined that licensing department did not receive incident reports for multiple episodes occurring between these dates.

As a result of today's visit, deficiencies are cited under Title 22, Division 6. An immediate civil penalty in the amount of $250 is assessed due to repeat violation within a 12-month period. An exit interview was conducted with Gurpreet Rai and a copy of this report was left with Gurpreet. Appeal Rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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 08/03/2022 04:18 PM - It Cannot Be Edited


Created By: Michael Bilger On 08/03/2022 at 03:43 PM
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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2022
Section Cited
HSC
1569.312(d)

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Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:(d) Being aware of the resident's general whereabouts…This requirement was not met as evidenced by:
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Licensee will submit a plan to ensure appropriate supervision of residents and knowledge of general whereabouts at all times.

Plan to be submitted to LPA by POC due date.
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Based on record review and interview, R1, R2, R3, and R4 eloped from facility collectively between 5-7-22 and 7-15-22 and staff was not aware of R1-R4's whereabouts. This poses an immediate health and safety risk to residents in care. An immediate civil penalty of $250 is assessed due to repeat violation.
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Type A
08/03/2022
Section Cited
CCR87211(a)(1)(D)

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Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports...including...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident, such as...unexplained absence of any resident.
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Licensee will submit a plan to ensure necessary incidents such as unexplained resident absence are reported timely and accurately to licensing department and per all other regulatory requirements.

Plan to be submitted to LPA by POC due date.
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This requirement was not met as evidenced by: Based on record review and interview, licensee did not ensure reports of multiple elopement episodes occurring between 5-7-22 and 7-15-22 sent to licensing department. This poses an immediate 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 King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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