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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 04/06/2021
Date Signed: 04/20/2021 12:52:57 PM



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
12/08/2020 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201208145316
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:
02:30 PM
MET WITH:Katrice CollinsTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility not administering residents' medications as prescribed.
Facility not assisting resident in arranging for necessary medical services.
Staff not according resident with dignity.
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: Facility not administering residents' medications as prescribed.
Based on records reviewed and interviews with residents the facility administered medications incorrectly on several occasions. The department reviewed medication errors that were reported 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.
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: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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 4
Control Number 27-AS-20201208145316
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: Facility not assisting resident in arranging for necessary medical services. Bases on records reviewed and interview with the Med-tech on 4/6/2021, the facility did not follow the discharge orders for R1. R1 was discharged from the ER on 2/2/2021 with instructions to follow-up with primary care physician in 3-5 days. The facility failed to follow these orders and R1 was sent back to the ER on 2/9/2021 for treatment of the same medical issues including vomiting, diarrhea and becoming unresponsive with prompted by the Med-tech Marilyn. The allegation is substantiated.

Allegation: Staff not according resident with dignity. R1 was receiving gabapentin three times a day which helped her significantly, along with PT and OT. R1 states that after moving into Wagner heights, she did not receive most of her medications for several days, including the gabapentin, and as a result, her neuropathy has returned and it has impacted her independence greatly. R1 has had an increase incontinence and required additional assistance with ambulation. R1 states that after the several days, she started getting the gabapentin for about a week but even during that week it was not administered correctly or consistently, and she has been without it again. She was unable to confirm dates. Based on the review of the medication administration record(MAR) for November 2020, the facility missed doses on multiple days from 11/3/2020 to 11/17/2020. The MAR is not filled out correctly, it is missing information and nurses notes on the back are incomplete.

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: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20201208145316
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
04/21/2021
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 A
04/21/2021
Section Cited
CCR
80078(a)
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80078. Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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The Licensee shall have an outside agency training on the care and supervision responsibilities. The Licensee shall send CCL proof of training for all staff. Upon completion of the training the facility will be send to LPA
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Based on interviews and record review, the licensee did not arrange for follow-up visit for R1. This poses an immediate health and safety risk to residents in care.
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proof of completion with an acknowledgment of understanding and compliance with this regulation.
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: 04/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20201208145316
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
04/21/2021
Section Cited
CCR
80072(a)(9)
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a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(9) To receive or reject medical care, or health-related services, except for minors and other clients for whom a guardian, conservator, or other legal authority has been appointed.
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Administrator will conduct an in-service training for staff regarding understanding of personal rights for client care and mandated reporting.
The agenda and sign in sheet will be forwarded to LPA by POC date or the completion of the training
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This requirement is not met as evidenced by:Based on interviews conducted and records reviewed, the facility did not insure R1's personal rights were protected as the facility did not provide medications and medical care, which posed an immediate health, safety, and personal rights risk to the 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4