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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 09/29/2022
Date Signed: 10/05/2022 08:53:47 AM

Document Has Been Signed on 10/05/2022 08:53 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
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: 44DATE:
09/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Belinda Guzman TIME COMPLETED:
02:45 PM
NARRATIVE
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LPA'S Kesha Lewis and Albert Johnson made an unannounced case management visit and to follow-up on the incident report for AWOL's and falls 9/10/2022-19/15/2022, also to verify correction of citation issued during the case management visit on 9/06/2022.

LPA determined based on LPA observation in the kitchen the fixed or Ansul system was serviced 9/15/2022. Based on records reviewed the facility did addressed the plan of correction from 9/6/2022.

Upon arrival LPA stood at front desk and was not assisted for some time. During the course of the visit LPA'S observed front desk is often left unattended by staff.

LPA'S was also informed by S1 that R1 is no longer at the facility, Based on records review facility is missing or has outdated needs and service plans for R1- R6 six (6) out of six (6) residents reviewed.

Continued on 809C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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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
VISIT DATE: 09/29/2022
NARRATIVE
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Also observed were three of three LIC 602'S identifying dementia as a diagnosis and further review from LPA'S determined that facility does not have an approved dementia program plan. LPA'S observed the program plan received from S1 is from 1999 under request from a different facility number # 397000308. The facility will provide the department an updated program plan to include dementia as a service to the client population by October 13th 2022.

Per California Code of Regulations, Title 22 the following deficiencies and civil penalties were issued during today's inspection. See LIC 809D.

Exit interview conducted. Copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2022 08:53 AM - It Cannot Be Edited


Created By: Kesha Lewis On 09/29/2022 at 01:23 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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2022
Section Cited
CCR
87763(c)

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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-R6 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: Based on records review of R1-R6 by LPA'S. This poses a potential health and safety rick to residents in care.
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Type B
10/13/2022
Section Cited
CCR87705(c)(5)

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87705(c)(5) Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually. This poses a potential health and safety rick to residents in care.
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The licensee will uptane a updated LIC 602 for R1-R6. licensee will submit a updated program plan with dementia care included by POC date.
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This requirement has not been met as evidenced by: Based on records review. LPA'S observed that residents with Dementia are not be medically assessed annually.
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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:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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