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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700580
Report Date: 10/19/2022
Date Signed: 10/25/2022 01:57:14 PM

Substantiated


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
09/28/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220928110601
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 3FACILITY NUMBER:
392700580
ADMINISTRATOR:CRISTOPHER WALTERSFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:4CENSUS: 4DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:WaltersTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff member inappropriately restrained resident while in care.
Staff member roughly handled resident while in care.
INVESTIGATION FINDINGS:
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Based on interviews conducted and records review, R1's IPP and intervention plans confirm that R1 is physically aggressive, quick tempered, impulsive and will assault staff and other residents in the home or at school. On the day of the incident R1 was incontinent and his roommate informed staff that his room was smelling, a request by R1's roommate to staff to have the room checked for the smells as a result R1 became agitated, broke his television, went to the bathroom and broke the bathroom door.

Staff held R1's wrist to stop the aggression and property destruction from continuing. R1 calmed down after sometime. There were no marks or bruising as a result of the staff holding R1's wrist and staff was able to continue with the care and supervision of R1 and other residents in care.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
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 3
Control Number 27-AS-20220928110601
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: WALTERS RESIDENTIAL HOME CARE 3
FACILITY NUMBER: 392700580
VISIT DATE: 10/19/2022
NARRATIVE
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Records reviewed support a higher level of care to avoid R1 being a danger to himself or others. Medication records obtained confirmed that R1 is not taking two medication that has been part of his medication regiment. These medications have not been discontinued by R1's primary doctor and were requested at the Telemed conference on the 27th of September 2022

As a result of this investigation, LPA finds the allegations to be (s) Substantiated -A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview conducted. A copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220928110601
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: WALTERS RESIDENTIAL HOME CARE 3
FACILITY NUMBER: 392700580
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2022
Section Cited
CCR
80072
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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:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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The facility will provide all staff with a refresher of the Managing of Assaultive Behaviors and if available the staff will be given training on restraints if this is part of the facilities program design.
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This requirement was not met as evidenced by the documented incident report that detailed the holding of R1's wrist. This poses a potential safety risk to residents in care.
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This information should be submitted by 10/31/2022 to LPA Johnson.
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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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3