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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 04/06/2021
Date Signed: 04/09/2021 09:42:58 AM



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
11/09/2020 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201109163338
FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:COLLINS, KATRICEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 68DATE:
04/06/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:M. Andrade Assistant Administrator TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff failed to properly administer medications
Residents are out of medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived unannouced to deliver findings. LPA was greeted by Assistant Administrator and later joined by Administrator Katrice Collins

Allegation: Staff failed to properly administer medications.
Based on records reviewed and interviews with residents the facility did not administer medications incorrectly on several occasions. The department reviewed medication errors that were reported to the department which detail other resident's medications being given to the wrong resident and missed medications. LPA also observed during the medciation review in the medication room with Admininstrator, Med tech and Assistant Admininstrator medications not stored properly and medication left on the top of the med chart in a disposable cup unattended. The allegation is substantiated. Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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 5
Control Number 27-AS-20201109163338
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: 04/06/2021
NARRATIVE
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Allegation: Residents are out of medication. Based on interviews with a staff the facility has ran out of medications for R1, R2 and R3. The facility did not report these medication error and LPA Johnson was unable to locate any incident reports for these incidents. As a result of this information and records reviewed the allegation is substantiated.

The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. ..

Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.

Exit interview was conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099, LIC 9099-D, and appeal rights were received. Administrator is to print out each report, sign it, and fax a signed copy to LPA at 916-263-4744.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/09/2020 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201109163338

FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:COLLINS, KATRICEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 68DATE:
04/06/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:M. Andrade Assistant AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff provided care and supervision while intoxicated.
Facility staff not properly trained.
Staff Forging Documents
INVESTIGATION FINDINGS:
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Allegation: Facility staff provided care and supervision while intoxicated. Based on records reviewed and interviews conducted for the alleged perpetrator there was discovery for action that required corrective actions, however there was no incidents reported or disclosed about the alleged perpetrator providing care while intoxicated. The Administrator, other staff and residents in care for denied smelling or observing any staff intoxicated while on duty.

Allegation: Facility staff not properly trained. Based on records reviewed, interviews with the Administrator and Assistant Administrator the facility is following the regualtory requirements for training. The facility has had medication errors and corrective actions for staff, as it maybe with reportable incidents. The facility provided due dilengence in documenting trainings for staff and med-tech this does not confirm or deny that the staff are not properly trained. Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20201109163338
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: 04/06/2021
NARRATIVE
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As a result, there is not enough evidence to support the allegation, therefore the allegation is unsubstantiated.

Allegation: Staff Forging Documents. Based on interviews conducted with the Reporting Party, the Assistant Administrator and the Administrator on several occasions the reported information is denied by the Assistant Administrator and the Administrator, however the Reporting Party confirms that the acts of forgery were witnessed by them. The information alleged to be forged was reviewed by LPA Johnson and he was unable to confirm or deny that the documents were forged. The allegation is unsubstantiated.

A finding that the complaint allegation(s) is/are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted with Administrator Katrice Collins via telephone and a copy of 9099 and 811(Confidential Names) was provided to Katrice via email, an electronic email read receipt confirms receiving these documents. Administrator will sign 9099, and send back electronic email to LPA Johnson on today's date.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20201109163338
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: 04/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care:(a) A plan for incidental medical and dental care shall be developed by each facility... compliance with the following:(5) The licensee shall assist residents with. This requirement is not met as evidenced by:
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The facility will have an outside agency conduct a training on medication administration, Medicaction storage, medication ordering and
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Based on interviews and records review, the licensee did not ensure R1 was being administered medication as prescribed. This posed an immediate health and safety risk to R1.
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medication verification for med-techs. Administrator will email LPA a training agenda and the agency conducting the training by 4/07/2021.
Type B
04/13/2021
Section Cited
CCR
87211(a)(2)
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Reporting Requirements
Occurrences…which threaten the welfare, safety or health of residents, 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 provide Mandated Reporter and Reporting Requirement training to all staff by POC due date.
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This requirement is not met as evidenced by: The Licensee failed to notify CCL of medication errors for R1, R2 and R3 missed medications This is a potential health and safety risk to residents in care.
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Please submit signature of those who attend the training and include trainer’s name, date and title of the training. POC due by 4/13/21
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5